Laserfiche WebLink
,wlinuI 6ni1L <br /> L ,'C <br /> L STREET ADDRESSSITE PHONE I WITH AREA CODE <br /> I • / 71 va <br /> ---'f y/f �.t_�r..a/�v1 ST <br /> ...�-- <br /> Y CITY STATE ZIP CODE 1 of Tanks <br /> 5x-clf7::-✓ C-F 1'ro� at Site T�-✓ <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> F <br /> F C/ Pel v/st CTC t SC/c✓i cC <br /> L - — _— —.—. __ __ ...__........ - -- --- _--- -.— ------- <br /> 1 MAILING ADDRESS APPLICANT PHONE 1 <br /> YITX AREA LODE <br /> NI CITY ----- v _ pI - Gi <br /> 11111�� r <br /> 1� �'--�- L_- <br /> 511P COD E of APPLICATION <br /> srPE ��ATE TYPE <br /> CLOSURE. IXETALLATION, ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A ---- ---- -- ...........--- _ _ _ .. <br /> T1986 1987 1988 1383 <br /> E TANK FEE = fo0.00 each TAHY, <br /> _ _ <br /> F ( Tanks x $50.00 1996 1381 1388 1983 <br /> A (sultiply-t-by fee for <br /> Ieach year applicable) <br /> ----------- <br /> STATE SURCHARGE = 456.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I __-- __-____.- _ ._ <br /> 1 1 Tanks x $56.00 <br /> ---- <br /> 1981 - 1388 1389 <br /> Y (enter amount and year) <br /> - - - _---- -_ ---- --- ... -__..-. -- ... ------ <br /> I, PERMANENT CLOSURE (Removal or Closure-in-place) - -- <br /> L ._ —.._- -------------- - --- -......_- -- -- ---------- <br /> 0 CLOSURE FEE = S-30.00 each TANK I Tanks pZ x (30.00 f OO <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) — - - — - <br /> E <br /> TENPOP.ARY CLOSURE FEE = $80.00 each TANK - - <br /> I Tanks------ <br /> PLAN <br /> _ --PLAN CHECK (Installation or Repair) — —'- —' <br /> 411 PLAN CHECK FEE _ $30,00 each SUBMISSION/RESUBMISSION f <br /> C (REPAIR — __- -.-._---- - - -------- <br /> f qAMK REPAIR FEE = (110. each TANK <br /> 00 1 Tankx f110.00 f <br /> A PIPING REPAIR/CLOSUP.E/REMOVAL (Fees are per hour, minimum one hour to be paid on plan suhmit}al) - — <br /> I ------------ <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION _ SAMPLING INSPECTION- - <br /> (when applicablewhen applicable) (when applicable) <br /> FEE _ (30,00/hr T l /pp <br /> ----- --- - FEE _ (3 _00/hr�---._-.._._._... FEE =-(35.00/hr.l _...... f- ` ppQ_ a- - <br /> TOTAL DUE f AO0 v� <br /> Orricr OSE ONLY <br /> ,g�4NN GGG��GOQG<NG! i R G09=GV IIGVGI NGV1111IIV�GV1111IIVU11111!DIIGVI!'IIGIIV!GIVIIVIIGpNIVIIIIGIIIIWIVIIIVIIIIGIiIIIIiIIIIIIIIIIIIIGIIIIIIIIGIIGIIVIIIIIIIIIIIIIIIIIIIGII!�GIIIIIIIiIGIIGIIVGIIVGGVIIG!111117GG�IGIIPIIIIGGVGINMGI000GINIGP <br /> CONP I LOC CODE DIST CODE AMOUNT DUE AMOUNT P.CVD CHECK /CASH RCVD BY DATE <br /> 32 <br /> P,ECEIVED PERnIT 1 <br /> ..... <br /> u 4�f� GNIiiU�I11 Vic NII@IIINNINII4�111G iPII�iICNNI!IIGI9INPIIII 9i 111 .11, !G!I!lii9!Ni ii t�'I�I � p 3H. <br /> T D . �� 1�1��° ��� NI IIINO IIVI lV IIIIIIIIIIIIIIIG!III IIIVI� ,IIIIIVII �61NNININNIINNINN!INNGAUIPING �G!NNIINI NN IIINI�IIIINP�m9PiVIIN'�JI��C��!V!N�PINm�� <br />