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ata iNMla 400" n1NNL4C a ft a a WA0Qk4 <br /> 4110+146jolpolk rINkla Awt�w <br /> AMMONMa ,artr numa� �a .rrraw. <br /> IILITY SITE NAME FACILITY CONTACT NAME <br /> ,74i.0 r9/1!DrQ f�,QTGI��/L ifD�/ $TEUFt/$DN <br /> ( <br /> FACILITY ADDRESS 160? Ae6o&,Y/T SITEPHONEo`"`h AW_5/ E <br /> ( /T7J� <br /> T CITY ST TE ZIP CODE • of TANKS <br /> Y STGCKTon/ y5206 at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NNM/IE <br /> `gr l MAI L1NL, ADDRESS APPLICANT PHONE Y WITH AREA CODE <br /> 20 1 S2 96s <br /> N CITY /�loQ�sT� STATE ZIP CODE TYPE of APPLICATION - d//�� <br /> T C,L� 5' CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) • $100.00 <br /> 1 $ <br /> V <br /> E TANK FEE $50.00/TANK (prior to Janxnary 1,1991) $170/TANK (after January 1, 1991) <br /> F If Tanks • 1986 1 1987 1 1988 1 1989 1990 1991 1992 1993 1994 1 1995 1996 <br /> A (mttiply N by fee for <br /> C each year appticable) S <br /> I <br /> L STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See CaLifornia H 8 5 Code, Section 25287 <br /> 1 <br /> T M Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter enfant end year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-(n-PLace) JTANK I.D. Y(s) <br /> L CLOSURE FEE - $53.00 per hour (3 hours minimum per TANK) K TANK($)_; X $159.00 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. M(s) <br /> R <br /> E TEMPORARY CLOSURE FEE $150.00 each TANK M TANK(s) K 5150.00 • f <br /> P PLAN CHECK (Install. Pian Review i Construction Inspections) TANK I.D. @(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) • $424.00 minimum S <br /> R REPAIR FEE (workplan review i cons tructlon Inspections) TANK I.D. N(s) <br /> E <br /> P TANK REPAIR FEE • $53.00 per hour (3 hours miniaWTANK) Y TANK(s) K $159.00 • f <br /> A -- <br /> 1 <br /> R PIPING REPAIR FEE . $53.00 per hour (3 hour minimum per facility • $159.00) f <br /> N CONSULTATIONS <br /> I UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 5 <br /> C FEE • $53.00/hr FEE $53.00/hr FEE = f 53.00/hr <br /> TOTAL DUE O0 <br /> OFFICE USE ONLY <br /> ... . ................. ...................................... <br /> New, ...�...o. .�a.w.w•www•x.rr.r' p� r:»w::siriwi.......... �a��r..........#Y........ <br /> wry €P'S'" "` "� 'f1T`ST"C '76iHbk'A`L'tlif"" flh�7C" '" 1!�'L'E(0Eff'�ii0" yAIE IIEZ'F111EH"":awi <br /> r � <br /> :.......................... .........._ ........... . ..... <br /> r�s�sww»wwwwwrw.:ww•wrwiiriw•wri�w�i�G�w"rii�ixwr'wiw'ii»wiwir:+riiw�iwiiiwwir�iwwww•ri•.•.••• ..•.•yn:�a:��••.•.•.•.••••• _ � <br /> srasrrararsaurwrrrerrsisrrawrwrarsrrrwrr.rr�rrwrwrwrrwrsnear.rrrarrrrs�iwwwsraarrrrs aiawarw�ia.r <br /> IN 23 Oil (REV 1/10/91) ft - Pwo 11 <br /> ssa� "— <br />