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- -....% -. A�. ., rIL- AL- I rT Le ab1Ra L. 1 <br /> IDER6ROUMD STORAGE TANK PROGRAM - FEE NORKSI , — <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> L STREET ADDRESS SITE PHONE 1 w"H AREA coos <br /> T m D u 7-2/ /4 L P.9�4K- <br /> Y CITY STAT IIP CODE 1 of Tanks <br /> MA-,nj_.TF—c- 4 ��� 9333 at Site / <br /> A APPLICANT/BILLIN6 NAME APPLICANT CONTACT NAME <br /> P <br /> P {M $M/4 L. i- �F—H '� VVl #72S rl A r- 4,9F H/2 <br /> L -- - <br /> I MAILING ADDRESS A LICANT PHONE 1 'IT" AREA CODE <br /> C .25� �E H/2 �c,r4 c-F .2� �� ��3 / z 70 ,) - 763 <br /> C �_._._STAT ZIP i1P CODE TYPE of APPLICATION <br /> rF CA -- C� L�S 33e CLOSURE, I9ETRLLRT9M, ETC.R£��/j�L <br /> FACILITY FEE=$100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> T 1986 1987 1988P <br /> 989 -- <br /> V — <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanis _ _ x 150.00 -1986 1981 - 1988 -�—1989 <br /> A (multiply t by fee for <br /> C each year applicable) i <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> +L— <br /> I 1 Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter iiiuit and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) — -- <br /> L ----- .-._,_------- -.-..--- _-_-..... -. <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tank; G x 190.00 f rj Q <br /> S -- -- <br /> U --- - <br /> E TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK —Ti Tanks x $80.00 1 <br /> P PLAN CNECK ( ns a a ion or — - <br /> L ----- --- ---- <br /> A <br /> N PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION <br /> R TANK. REPAIR FEE = 1110.00 each TANK 1 Tanks x 1110.00 <br /> -- --- _ <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I - ------ - --.._.. —-- <br /> R UNAUTHORIZED RELEASEEVALUATION AMPLING INSPECTION <br /> (when applicable) (when applicable) v en apollcalf <br /> FEE = 130.00/hr FEE _ (35.00/hr FEE = 135.00/hrr 1 <br /> TOTAL DUE f S (o <br /> OFFICE USE ONLY <br /> �INlGGIINIII GNiI(VMNIICGIIGNNICIGNNGNNIINGIII!NGNIGNCNGGIIIIIIVCNGNIIICCGNN WNgNNGNIINCGNCIGNCIGGIINIINIGIIiiNIGINIINIWIVUIVIGNIIVIIVNI NINIIIIUNVINIVCNVIG N�INGNVNCNIIO!IVIINCCNCINICIIGgNV�VNGfVIGNINIVIVgNVVNIIgGuq!Ti <br /> SWEEPS 1 COMP 1 LOC COO,�DDLE DIST CODE AMOUNT DUE AMOUNT RCVD CH CK /CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> 11123Y(� N GI�V CIIIigIG�NIGIIJVICNINIill .lliIJINIIIGIGN !GgIW..11111N!NGIIIIdQIIIIIIN Alli..IIIIIIIIiIIIGIIJCICIi�II�II�IICUIICINGICINIIN III I �I) i <br /> "�9'� 0 �°'' v4�!�W G�I.uNIII�uu:INI ININIu�No�GN�N�um�u�,uGN <br />