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UNDERGROUND STORAGE TANK PROGRAM - FEE VORKSHEET <br /> ITE NAME FACILITY CONT, NAME <br /> UN/ ✓ J/�c, NOG6 rb'O� ' TT k4,/ <br /> I STR T ADDRESS /� SITE PHONE 1 (with Area Codel <br /> I /�V0 L/j <br /> T /C�,4 L 9�. o — 9 FZ>?— O v <br /> Y CITY STATE IIP CODE 1 of TANK'S �y <br /> /� C'9Lr 95g,)p & at Site of <br /> A APPLICANT/BILLING NAME APPL NT CONTACT NAME <br /> P p � <br /> I MAILING DDRESS APPLICANT PHONE 1 (with Area Code) <br /> A l J. <br /> 10"N CITY S ATE Z CODEPE of APPLICATIONn/� pp� �� 3�rlosure, Installation, etc.) LGOc�l'e6 <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 <br /> T <br /> I S <br /> V <br /> E TANK FEE _ (50.00 each TANK <br /> tSTATE <br /> ks _ _ $50.00 1986 1987 1988 1989 <br /> tpfy 1-by fee for <br /> year applicable) f <br /> SURCHARGE _ $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> ks s (56.00 1986 1987 1988 1989 <br /> r mount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks'�;L_ s 190.00 f (?o , Q 0 <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK 1 Tanks 1 $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE = $110.00 each TANK 1 Tanks z $110.00 $ <br /> p <br /> A <br /> I PIPING REPAIR/CLUSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = S30.00/hr FEE _ $35.00/hr FEE = $35.00/hr S <br /> TOTAL DUE $ <br /> OFFICE USE DALY <br /> F <br /> COMP t LOC CODE01ST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVO BY DATE RECEIVED PERMIT 1tthIvyo Iso, 00 4 s � <br />