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4DERGROUNO STORAGE TANK PROGRAM - FEE WORKSV" <br /> F FACILITY/SITE NAME - FACILITY CT", XCT NAME <br /> L SIR A�OOR�SS SITE PHONE 1 WITH AREA CODE <br /> Y CITYSTATE IIP CODE 1 of Tanks <br /> — 5Zo- S -05 at Site <br /> — — -- -- — <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I MAILING ADDRESS APPICANT PHONE 1 WITH AREA CODE <br /> A . P� cls_ L2�-- 7---- <br /> N CITY TAT IIP CODE TYPE of APPLICATION <br /> T �^ -- -- 195:1 CLOSURE, IHE/ALLATIOH• Erc. 0 IDSU r e, <br /> FACILITY FEE = $10000.500 each SITE ADDRESS per YEAR TOTAL <br /> R� -- <br /> — ------ _386 - I'387 — 1388--1383 <br /> r _- <br /> 1 s <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanksx t50.00 1386 1387 1988 1989 <br /> A (EultipTy_f_by fee for --- <br /> each year applicable) — — ----� f <br /> L STATE SU,CHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25281 for applicability) <br /> T 1 Tanks x $56.00 1396 138 <br /> 1381 8 1383 <br /> Y (enter aenunt and year) — — - —_� <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) L <br /> L - -----— - -- <br /> 0 CLOSURE FEE = $30.00 each TANK I Tanks j__ x $90.00 f <br /> , <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E-- j <br /> --------- ---- -- <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK: —TI Tanksx t80.00 - f <br /> PIPIAN CHECK (Installation or Repair) <br /> L---- - — ... -— - -- — --- ------ -- --_._....-..- <br /> A <br /> I11 PLAN CHECK FEE _ $30.00 each SUBMISSIGN/RESUBMISSIGH f <br /> it T-- -- <br /> IREPAIR <br /> ----- --- — - <br /> RI TANK REPAIR FEE _ $110.00 each TANK --- — (I Tanks --x $110_00 - <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I -"---- — -- — <br /> R UNAUTHORIIED RELEASE EVALUATION COt(STRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) $when applicable) (when applicable) <br /> FEE = 00.00/hr — FEE _ $35.00/hr —— FEE _ $35`00/hr1-- f <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> HIM '11mill ON <br /> zij-uj11xLVIbLU <br /> COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1CASH RCVD BY DATE RECEIVED PERMIT 1 <br />