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+ I :GROUND STORAGE TANK PROGRAM - FEE WORKSHEE <br /> �./.--------._.-----•--- --_.,SSSS.-----, -- ---------_.._. <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C sL -��T✓-C <br /> &Acp, Ala,'q 4A <br /> 1 — I _ / <br /> L STREET ADDRESS SITE PHONE 1 WITH AREA coo. <br /> — <br /> YCITY STATE ZIP CODE t of Tanks <br /> CA- f at Site <br /> `5,31rAPPIILICANT <br /> `___- -Z-�- -- - -- <br /> A APPLICANT/BIL 6 NAME CONTACT NAME <br /> P <br /> P <br /> L .._u1 L----``-qua__-.;��_F►s-�-----.._.._.__.._.._---_.—. '�'�,�c N . Fts KI MAILING ADDRESS ICANT PHONE t WITH AREA CODE <br /> . <br /> N CITY SAT ZIP CODE TYPE of APPLICATION <br /> �.1 CLOSURE. INSTALLATION, ETC. <br /> - -- - --- -- -- ---SII-- --_- ----__ <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> ASSSS... ----------- - - - - -- _.-_ -- - <br /> 1� .�_-19J ..-19t� - f - O <br /> V- <br /> E <br /> E TANK FEE = $50.00 each TANK <br /> F t Tanks _ _ x $50.00 1986 1987 1988 $989 - � <br /> A (multiply I by tee for ✓ � ---- <br /> C each year applicable) f <br /> I -------- - -- - �- - -�-�-- <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25207 for applicability) <br /> ISSSS- -- --- -- - - - - <br /> T t Tanks A x $56.00 1986 1987 1988 1909 <br /> Y (enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L ------- _ -- ------ ._.-_. _._.. - - -SSSS -------------- <br /> -- -- <br /> 4 CLOSURE FEE = 190.00 each TANK- _ - - t Tanks__,2, $90.00 f T Q <br /> U ---------- - ----- -- -- -- ------ .. <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E -- -- -------- --- - - --- Fi <br /> TEMPORAP,Y CLOSURE FEE _ $80.G0 each TANK t Tanks x $80.00 <br /> P PLAN CHECK (Installation or Repair) <br /> L -- <br /> (H PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> P. TANK REPAIR FEE _ $110.00 each TANK <br /> E ---- <br /> p - <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I _-- --- ------ ------ <br /> R UNAUTHORIZED RELEASE EVALUATIONICliliNSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) when applicable) (when applicable) <br /> FEE $'0 00/hr E = $35.00/hr FEE = $35.007r-- -----� ---- - - ----- _ ---- - -- ---- <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> jpllll!li!!PJQQQQQVQQQQIIQQQIQIIQQIIQUI!IQIQQIQII�IIQIQII!II9!!QQQIIQQQVQQIIIIQIIQVQ91QIQ91QIQ9QIQ�IQQY�QIIQNIQQIIIIQQQQIIQIOIIQ!IQQQIQ@IIQIIIQIIIQIIQQ��iQIQIIIiIGQIIQIi�IQIIQIIQIIIIAI�IQQQIIIIIIII!IIQIQIQQIQGIIQI QQQQQQQQQQQImiQQQQQQII�IQIIII'!�GQQIIIN'tlIQQIQ�IQ!!IIN�IIQIIQQII <br /> !I SWEEPS / COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECENEO PEP,MIT t <br /> II _SSSS.. Fn.�c3� SSSS._._ o��.c�% I �l.� ai✓ ��`t I I �� f�—� xt �� <br /> ���1111�Q91��@Pll�!�;�� �!!Irl!!J����119.IQIQUI!QIIINI!I,iQIIQiIIQQ9!IPIIQIiIIQQQ!hIIQ.!!!Q.911!I@QQQ!II!QQ!I!I!UIIuIQI!I!Qli!nl��l!III!QIIIIIIQ!I!I!IQI!IIQI!Ii!Q,IllgllilQl!QQQiIIIQIQ!I!QQ��II!I. iIQQ�I!QIQI9G1QnQQIL.I�IIQIQIIQII!IQ!IIIIBQIQIIQ.IIiIIQ9�QV;�IIIQ..IIIIIII�tl�GQVI!�IQI!IIQIJI!QV� <br />