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UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY/SITE NAME <br /> FACILITY CONTACT NAME <br /> L STREET ADDRESS SITE PHONE I (with Area Code; <br /> r 757 Z- . <br /> Y CITY / STATE ZIP CODE I of TA14919 <br /> lf?4 7 . C{¢ — at Site <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> P <br /> L PM21-ioy1 <br /> I MAILING ADDRESS APPLll;ANT PHON I (with Area Cod ) <br /> N CITY STATE ZIP CODE APPLICATION <br /> T /UIE�,U� 04 20j�, lC osur Installation, etc.i <br /> A IAC EE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1586 1987 1988 198'3 <br /> T <br /> 1 ; <br /> V <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanks x $50.00 1936 1981 988 1.339 <br /> A lrultipry I-by fee for <br /> each year applicable) f <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25281 for appli�a r <br /> I <br /> T I Tanks x $56.00 1586 1981 1'3B8 1'339 <br /> Y (enter ai65ht and year) <br /> C PERMANENT CLOSUR ( caval r Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK t Tar,kS__jx $90.00 — <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tine for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK I Tanks x $80.00 t — <br /> P e air) <br /> L <br /> A -- <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> R <br /> E TANK REPAIR F 0.00 each TANK t Tanks x $110.00 ; <br /> P <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees ar hour, ainiaua one hour to be paid on plan subsittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTIOII <br /> FEE _ $30.00lhr FEE _ $35.00/hr FEE <br /> TOTAL <br /> OFFICE USE ONLY <br /> ESNEEPS COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED PERMIT 1 <br /> BTJCa7s O3 S�2/ X901 ��OG 3 3i2 <br /> F. . �:X! .nr. -is�'OM•:'{M"".Y,x. 'tl.....tl '(r,i •MMl `C Y.. <br />