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' 71HIN .IUAUU11V LUUAL MtALIN U151K1L. 1 <br /> -RGROUND STORAGE TANK PROGRAM - FEE kORKSHEE�' <br /> F FACILITY/SITE'NAME fACILITY CONTACT NAME <br /> L STREET ADDRESS lyRb Boc(rhn�1 S'���{ SITE PHONE f WITH AREA .ODE <br /> T 14 <br /> Y CITY STATE ZIP CODE f of Tanks <br /> at Site _�► 1� <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P l <br /> � i-418t <br /> I MAILING ADDRESS APPU F,ANT PHONE I WITH AREA CODE <br /> A giss..i_c� - 5 �e�- __. y/ _ �L. �l� <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> I ^^' -•----__---- 9ZI�� CLOSURE. {NETALLATION, ETC. <br /> FACILITY FEE = S100.00 each SITE ADDRESS per YEAR _ -- — — — TOTAL <br /> A . _ _ _ _ _ <br /> I1 —_—I <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks z f1986 1`181 1988 1989 <br /> A (multiply f-by feeee for ---- <br /> C each year applicable) — -- <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH t SAFETY CODE Sec 25281 for applicability) <br /> I _ <br /> T 1 Tanks z $56.00 1986 1987 1388 1383 <br /> Y (enter eiount and year _ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tanks z f30.00 f <br /> P. TEMPORARY CLOSURE (Only allowed one time for up to two years) i <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks z (90.00 S <br /> r ----— ------- --- _ _— <br /> IP PLANCHECK (Installation or Repair) _ <br /> L -- -- — ----..._—----- --- -- ------- --- -- <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ <br /> I <br /> REPAIR -- -------�----- <br /> �------- — — ---- ----- — <br /> R TANK. REPAIR FEE _ $110.00 each TANKI Tanks z SI10.00 f <br /> E - - <br /> P — <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on pro submittal) <br /> I -- — — <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 130.00/hr _ — FEE = 135.00/hr --- --- FEE = f35A00/hr — — $ <br /> TOTAL DUE f Q aD <br /> OFFICE USE ONLY <br /> V�9I��V NIIVNVCVQV�VQVVNQVIQVQ6GInIGQVNIIIII!IQVIV! IVI@!IIIVIIVIIVQNIIVIIIIIGIIIVIIIiI!VIIflNI�GpIQIgIGIINIIVQVNIINIVIINII!IINGIV!INNIINfiIGQV NVVNVQQVVIGIflgm <br /> SNrEEPS 1 COMP i LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHEC ASH RCVD BY DATE RECEIVEDIt, PERMIT i <br /> ioa�O ..... <br /> UR Xtylsku <br /> � INNN4flIIIV.QQINflI�B�GI�II!@!I!V':IN iPINI!NPflNVI!NNNI@GGQ Q9!rdVIVIV VVIVIVVM�CGVIVI iNGI SIL N . <br />