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M�AL 1H LIS , K1C1- <br /> f (AGILITY/SIZE NAME RGROUND STORAGE TANK PROGRAM - FEE YORKSHEL. <br /> A FACILITY CONTACT NAME <br /> I G L11,0 C.5i <br /> o. <br /> L STREET ADDRESS <br /> I <br /> T SITE PHONE 1 -Tw wwcw coo, <br /> Y CITY <br /> STAT IIP CODE 1 of Tanks <br /> A APPLICANT/BILLING NAME at Site <br /> P <br /> P APPLICANT CONTACT NAME <br /> L <br /> I MAILING ADDRESS <br /> L <br /> A APPLICANT PHONE 1 wl- —&A coo[ <br /> N CITY <br /> 1 STA1 TIP CODE 1YPE of APPLICATION <br /> clonus[, Iw�Te�Ln„ow. RC. <br /> A-FACILITY ru _ (100.00 each SITE ADDRESS per YEAR <br /> — <br /> C TOTAL <br /> 1 1906 1907 1988 1989 <br /> 1 /,r, ": <br /> V is <br /> E TANK FEE _ $50.00 each TANK $ �' <br /> F 1 Tanks r $50.00 1906 <br /> A Imultipiy-I by fee for 1987 f90B 1989 <br /> C each year applicable) i. ... <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks ,�_ t (56.00 1986 <br /> Y (enter mount and year) )907 1908 1909 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L �--- C <br /> 0 CLOSURE FEE = t90.D0 each TANK - <br /> S 1 <br /> U ianks_�_ t f90.00 $ r <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two yeas) <br /> E <br /> TEMPORARY CLOSURE FEE _ (00,00 each TANK <br /> 1 Tanks r $00.00 t <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> f <br /> REPAIR <br /> R TANK REPAIR FEE _ (110.00 each TANK <br /> 1 Tankz _ a $110.00 $ <br /> A PIPING REPAIR/CLOSURC/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <br /> ------------- <br /> k UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPCCTION <br /> (when applicable) (When applicable! <br /> Ivhen appli <br /> FEE = $70.00/hr FEE (able) <br /> $35,00/hr f <br /> OrrTCF USF my TOTAL DUE <br /> pig „ i <br /> SWEEPS 1I '"'� �' ' III'111111'll'6111116'PJIpIhIII11nIIIIIIPuu!I <br /> COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVB BY DATE RECEIVED PERMIT 1 <br /> .IPmgml T IIINII pVflghl 1! 'r' '� <br /> h R UII11If9p0'N!IUI�'Inllhtlll'l�Il"I"I'll""� 11 1 f r o IN I <br />