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'SRGROUND STORAGE TANK PR06RAN - FEE IIORKSHEF <br /> FACILITY/SITE NAME FACILITY ON ACT NAME <br /> 0\A ry w /d i�201 <br /> b� t�vew.,�r owlca <br /> STREET ADDRESS �ic <br /> SITE PHONE 1 ( ith Area Code) <br /> T 400a} EL Do2Allo BLv0 u <br /> Y CITY STATE IIP CODE / of TANK'S <br /> S �K�z4 Cf} R at Site �2� 5000 GAL <br /> P APPLICANT/BILLING NAME APPLIT CONTACT / <br /> L � "I-'n` '1 'G b7 �V/O'YYl )LV U N <br /> L <br /> I MAILING ADDRESS APPLICANT HOME 1 (with Area Code) <br /> C X44 3 1 N q <br /> A c "76 <br /> N CITY <br /> T STATE IIP CODSTYP; PPLICATION <br /> M D�OLSY osur Installation, etc.) <br /> A FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C <br /> T L 1986 1987 1988 1989 <br /> I f <br /> V <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanks z $50.00 19116 1987 1988 1989 <br /> A (aultipTy 1-by fee for <br /> C each year applicable) f <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH i SAFETY CODE Sec 25287 for applicability) <br /> 1 <br /> T 1 Tanks z 156.00 1986 1987 1988 L98g <br /> Y (enter iiouot and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = 190.00 each TANK 1 Tanks z $90.00 f <br /> S <br /> OU <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK 1 Tanks z 180.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION 1 <br /> F. REPAIR <br /> E TANK REPAIR FEE _ $110.00 each TANK <br /> P 1 Tanks _ z 1110.00 f <br /> A <br /> 1 PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = 130.00/hr FEE = 135.00/hr FEE _ $35.00/hr f <br /> f 5 0 0 0 <br /> OFFTCE USE OMLY TOTAL DUE <br /> Z�WEP,SI COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> 0 PA6I 3 �t5o ' y5� _ 10 -7 Tp- <br />