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u, sKuUND STORAGE TANK PROGRAM - FEE VORKSHEEr'F <br /> A FACILITY/SITE NAME <br /> FACILITY CONTACT <br /> C _ <br /> I <br /> lJCS�c�N/�lEic�1 SES✓icb / . <br /> L STREET ADDRESS <br /> 1 SITE PHONE t YI TN ..c. loll Y•; <br /> Y CITY <br /> STAT IIP CODE t of Tanks r <br /> at Site <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> P _ <br /> L <br /> 1MAILING ADDRESS <br /> C APPLICANT PHONE NITN ARG cocC 'a <br /> e JD <br /> N CITY { <br /> — n <br /> i STAT ZIP CODE APPLICATION <br /> CL=OURC INSTALL.TION, CTC. {* <br /> FACILITY FEE _ $100,00 each SITE ADDRESS per YEAR ` <br /> A <br /> C TOTAL <br /> T 1986 1981 1988 1989 <br /> V <br /> E TANK FEE.= $50.00 each TANK $ <br /> 1: <br /> F f Tanksa 150.00 1986 1587 <br /> A (lint, I by fee for 1988 1989 <br /> C each year applicable) — <br /> L STATE SURCHARGE _ <br /> ( $56,00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) <br /> T 1"Tankil 'I $56.00 1986 1981 <br /> Y (enter uount*and year) 1988 1989 <br /> tis.. . <br /> f <br /> C PERMANENT CLOSURE (Reaoral 6r Closure in-place) <br /> L <br /> 0 CLOSURE FEE = 190.00 each TANK <br /> S Tanks !Y- z $90.00 1 <br /> U 1 T 60 <br /> R TEMPORARY CLOSURE (Only alloved one till for up to tvo years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK <br /> I tanks <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A r: <br /> H PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION S3-)1A13S 1 f <br /> 3H 1tl1N3WN0a1AN <br /> REPAIR <br /> R TANK REPAIR FEE = 1110.00 each TANK <br /> P t tanks_____ s SII 0 1 3 3 2? s s <br /> 1 A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, cinicuC one hour to he paid on p an suhaittal) t <br /> R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION <br /> (vhen applicable) SAMPLING INSPECTION <br /> (vhen applicable) <br /> (when applicable) <br /> FEE = $36.00/hr FEE _ $35.00/hr c <br /> FEE _ $3 .00/hr $ <br /> OFFICE USE OILY TOTAL DUE $ o <br /> rPl)II .! <br /> SUEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED <br /> PERMIT t <br /> 2TEVfSET1� � .4 I .I 11 ml'„ T ,R. r ;lid,;. _YM M ri�:wt�n�m�lrm�pnj7 ypep+ll'r'Nlfg9e ,RFtr•YI +,W <br />