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(FACILITY COt�CT NAME <br /> ---Mt+/ ��H 2 <br /> L STREET ACTRESS - - <br /> T ---�Q - SITE PHONE 1 Y1TM AREA coo[ <br /> P --- _US.i. k Dr. �y 823-7�3y 3 —i�7u <br /> Y CITY STAT IP CODE 1 of Tanks <br /> __ cul- at Site <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> 1 MAILING ADDRESS -— <br /> Z� L�!E 2 � C C APPLICANT PHONE I ulf" AREA cae[ <br /> tCA - ---ITYSTATIPCODE PLICATION <br /> —_.--..-.— .—i •m�11L� �;,3 cla[aR . MerAllMtoN. [rC. <br /> rFACILITY FEE 1100.00 each SITE ADDRESS per YEAR <br /> A _ TOTAL <br /> C 1986 <br /> i - -- - 1981 1988 1989 — <br /> I <br /> E - - <br /> ETANK FEE _ $50.00 each TANK $ <br /> F 1 Tanks _ _ x 150.00 1986 1987 1988 <br /> A (lultipiY f by Iee for (989 --'---- <br /> C each year app licable) - <br /> I --- --�__�_- <br /> L STATE SURCHARGE _ $56.00 each 1 <br /> TANK (see CA HEALTH 6 SAFETY CODE Sec 15287 for applicability) <br /> T 1 Tanks x $56.00 1986 1987 <br /> Y (enter iiouit and year) 1988 1989 <br /> C PERMANENT CLOSUP,E (Removal or Closure-in-place) <br /> 0 CLOSURE FEE = $90.00 each TANK <br /> U - 1 Tanks___ x $90.00 $ <br /> P. <br /> E TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK — <br /> - ----- 1 Tanks x (80.00 $ <br /> _ - ------ <br /> PIPLAN CHECK (Installation or Repair) <br /> L - -------- -..--- - -- <br /> N ------ <br /> IN PLAN CHECK FEE = 130.00 each SUBMISSION/RESUONISSION <br /> -- - $ <br /> I ]REPAIR — <br /> F. TANK REPAIR FEE = $110.00 each TANK <br /> 1 Tanks z (110.00 <br /> - - <br /> E ... -.—.---- - - ---- - -- - ...__ - $ <br /> A PIPING REPAIR./CLOSUPE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> f - - <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION <br /> (when applicable) (when applicable) SAMPLING INSPECTION <br /> (when applicable) <br /> FEE _ $30.00/hr FEE _ $35.00/hr <br /> - ---- - <br /> FEE = f35.00/hr - <br /> _.-- $ <br /> -- TOFAI DUE f <br /> OFFICE USE ONLY <br /> CE�NAI@P�G�!fV�i6�la'IWG =EPS 1 COMP 1 LOC CODE DIST CODE AMOUNT CUE AMOUNT RCVC /BECKr��ICASH RCVC BY LATE R�- -oma <br />