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aT UNDERGROUND STORAGE T;IN: PROGRAM FEE WORKSHEET h <br /> ....... -- — <br /> J/SITE NAME FACILITY CONTACT IIAMt,/ C ;} <br /> _._. <br /> SITE PHOtIE T YI iM A+cA pope x <br /> CT ADDRESS STATE - i[. CODE t of Tanks i {R <br /> TTY lat Site I 1f <br /> iA APPLICANT/BILLING NAME APPLICANT CONTACT NAME } <br /> IP 1 <br /> .- ...-..._ - <br /> L - " WITH ARG CODE <br />'I MAILING ADDF.ESS APPLICANT PHONE I 4 <br /> 3 <br /> A a13 <br /> _ _ ...._S --- '---- <br /> R C(T4 �f/(�/ /� II(15 TE y/]�IP CCOD/�E TYPE APPLICATION <br /> ✓• `---_...-_-•---...__.___l._ ._4 �4.^.X .__ ..uAE. INSTALLATION, CTC. <br /> — — -------- I ' <br /> ---- -.. _----------- ..._... ._.._.__................- <br /> FACILITY FEE =..4100.00 each SITE ADDP.ESS per YEAR TOTAL } <br /> * 1386 1907 1300 1303 — /,�y p C D i <br /> i I - -/- -f - f �CytJ /DJ f <br /> e <br /> --- - '. <br /> E TANK FEE = f50.00 each TANK } r <br /> ultiply <br /> i i Tants _ _ x s50.00 1986 4387 <br /> 199(3 (389 _ 15 9J f <br /> A (mf by fee for <br /> C each-year applicable) v�. SO SO —' i III <br /> L STATE SURCHARGE = S56.00 each TANK (see CA RI 6 SAFETY CODE Sec 25287 for applicab 't •;1 <br /> , <br /> 1 I Tants l x.5600 1'396 _ 190] 1308 - 130'3 /yya <br /> Y (enter iiouil and year-- - --._. .__._.y__... _....___....__.. ._.._.-------_- -._.- ---- <br /> 'C PERMANENT. CLOSURE (Removal or Closure-in-place) % <br /> _.... .._._..._......................... <br /> -------- E <br /> 0 CLOSURE FEE _ $•30.00 each TANK L I Tanks__- x f90.00 f 90.00 F <br /> U — — — -- _._.------- <br /> I. <br /> ----P. TEMPORARY CLOSURE (Only ;[loved one tine for up to two years) <br /> ._.......................... <br /> ..._.._— — <br /> TEMPORARY CLOSURE FEE _ S80.00 each TANK I Tanks x f .00 f <br /> 6 PLAN CHECK (installation or Repair) - <br /> L <br /> IIIPLAN CHECK-FEE _ $30.00 each SUBMISSION/RESUDMISSIOII <br /> rt <br /> kEPAIR - ! <br /> F. TANI: REPAIR FEE _ $110.00 each TANK - I Tants x S 10.00 S i <br /> ---- <br /> P . ......... -- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) , <br /> R UNAUTHORIZED RELEASE-EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> When-applicable) , (when applicable) (when applicable) It; <br /> -•--•--- - .—. -........_...... -..... --- - ._.....1 <br /> . <br /> TOTAL DUE t T. <br /> /484 `Ia cn. Q r �.o <br /> OFFICE USF OY.(Y- <br /> e qBq%°+Igllgh1%IuP%f11G911%II%%gggl!' II!H!C[ill%PigV%%ITV%ilq%g7gllkgq lfl!i01gIWIII!iI.IdI��nGiiNNNiI&Rfggg9�(��"'Il�l�GfiA�F:n t� <br /> SWEEPS I COMP i LO(: CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY I DATE RECEIVED PE9.MZT I <br /> 9 5 <br /> 3Ok Str .. __.... _.-_ .._ . __II--- <br /> , q%? ,5gmgP°qi�q"Vqx."!;6P�2' q%9'i'.T'19%%111 a�lall%!I%ilNlalf P'1VJq%JI%q�%�9TVI%Ill�'q%%%a°�:q��4$'q" injig'..0 lriu <br /> �. n , <br />