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—.....Ma. 11ces11-1H I)IS-1It1Cl" <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> f FACILITY/SITE NAM[ <br /> A FACILITY CONTACT NAME <br /> l <br /> L STREET ADDRESS SITE PHONE 1 WITH ANCA COOK <br /> 40Y CITY STAT 11P CODE 1 of Tanks <br /> at Site <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 <br /> C RITA ANON COD[ <br /> A <br /> N CITY <br /> T STAT LIP CODE TYPE of APPLICATION <br /> CLONOA[. IwNTAl Lw11mN. [TC. <br /> FACILITY FEE [ 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 190E 1907 1908 1909 <br /> t <br /> I <br /> V 1 <br /> E TANK FEE f 150.00 each TANK <br /> 1 Tanks 1 $50.00 1906 1907 <br /> 1908 1989 <br /> A UuIllply I-by lee for <br /> C each year applicable) <br /> f <br /> 1 1 <br /> L STAT[ SURCHARGE N $56.00 each TANK (see CA HEALTH L SAFETY CODE Set 25207 for applicability) <br /> I <br /> T 1Tanks : 156.00 1906 1907 1908 <br /> Y (enter iiiuit and year) 1909 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEC = $90.00 each TANK <br /> U 1 Tanks _ 1 $90.00 1 D� <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $00.00 each TANK <br /> 1 Tanks 1 t00.00 1 <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE m $70.00 each SUBMISSION/RESUBMISSION OV 8 10:10 <br /> t <br /> REPAIR <br /> r: <br /> ENVIRONME^JGTNLP._ <br /> HEAL <br /> R TANK REPAIR FEE = 1110.00 each TANK <br /> E 1 Tanks 1 $110.00 1 <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 EVALUATION CONSTRUCTION INSPECTION <br /> Ivhen applicable) (when applicable) SAMPLING TIOH <br /> (when appllicablicable) <br /> fCE = 170.00/hr FCE _ $75.00/hr <br /> fCC = $75.00/hr $ <br /> OFFICE BSE OILY TOTAL DUE — <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT REVD CHECK I/CASH KCVO DY DATE RECEIVED PERMIT 1 <br />