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FIFACILITT/S!TE NAME <br />h trlti-IE _Qc <br />I <br />L STREET ADDRESS <br />Y CITY - <br />k APPLICANT/BILLING NAME <br />1 NAILING ADDRESS <br />flCIT? _ <br />,1'UMUU1N LUUAL 11L-ALTI-3 DISTRICT <br />UNDE 'UND STORAGE TANK PROGRAM FEE WORKSHEET - <br />�/ _. - <br />�-- <br />FACILITY CONTACT NAME <br />--------- -r;no-bo� om. <br />j� SITE PHONE X °1 TN AREA CODE <br />-.......---...._....__ ...-2r0-9..----- <br />STATE 71P CODE If of Tanks <br />at Site <br />IAPPLICANT CONTACT NAME <br />APPLICANT P ONE I WITH AREA CODE <br />ZIP CODE TYPE of APPLICATION <br />v11 LL -1 CLOOURE, IHSTAILATIOH, ETC. <br />Al FACILITY FEE = $100,r0 ea h SITE ADVECS per YEAc <br />1388 3 <br />1386 ._...I- <br />.....1381 1...._....._ -------L-.-- 19(3 <br />E TANK FEE = SSD.00 each TANK <br />F I Tanks x S5O.00 1986 1987 1998 198'3 <br />A (multipiy-F-by fee for - -.-.---------...-----..............._..-.._.-......---------.L...._----------------- <br />C each year applicable) -- <br />L STATE SURCHARGE = S56.00 each TANK (see CA HEALTH A SAFETY CODE Sec 25287 for applicability) <br />T I Tanks -N. 556.00 1'396 r 190 <br />unt7 1 1988 I !98'3 <br />Y (enter amoand year) - - - - - - -- - --- -- - - -- T <br />• f <br />C PEP.MANENT• CLOSURE (Reaoyal for Closure -in-place)' <br />L----- -- --......_._.................._...-....__- _- ... ..._._..-......_ <br />5 CLOSURE FEE = S90.00 each TANK I S Tanks 3 __ x f90.00 S <br />U- _... .._------ ........-._...._........_..... <br />_ R TEMPORARY CLOSURE (Only allowed one tine for up In tvo years) <br />E _-1 _ <br />TEMPORARY CLOSURE FEE _ $80.00 each TAN); I 1 Tanks x E9U.00 f <br />------------ ---,._---------------- --- -__........ ..---.._..---_----------... ...... ---- <br />P PLAN CHECK Plnstallation or Repair) .. <br />L-- - - _------- _...._...._._.........-..-.._._......_- ................ - .._.. _._....---- - - --- <br />A I . <br />H PLAN CHECY._FEE = S30.00 each SUBMISSION/RESUDHISSION S <br />REPAIR , <br />R TAN); REPAIR FEE = $110.00 each TANK I I Tanks______ z . t <br />E---- - --._:.._...--.__._-.-__._........._..._......__..........................__.._........_...... <br />.. <br />F" <br />_......------ <br />........ - - <br />A PIPING REPAIR./CLOSUP.E/P,EMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br />I _ <br />R UNAUTHORIZED P,ELEASE.EVALUATI'OH CONSTRUCTION INSPECTION SAMPLING INSPECTION <br />(when -applicable) (when applicable) When applicable) <br />FEE <br />:!i:30. 00ihr. - — -fcE 135.00/hr� ..................._ FEE = SOS.OUIhrI t <br />.... .... .-.._._....... -- ... --_-_ ---- <br />TOTAL DUE <br />OFFICE USE OXLy <br />:J <br />TOTAL <br />ate.fl9�V��OCt9Vif ji' I�M2�P91•.IIVI IVVII�VIV!'tl�IfpIIIIIIIIVVVV19Vlllll!IIIVIIVIIiIIIIVNiIV'dill!II�IIV11kflV�I�li91�IIVl!il!fVl�!MfiiIN�IVV9 VV�fIWPPIP�� <br />SWEEPS 1 LOttF i LOi. CODE 01ST CODE AMOUNT DUE AMOUNT PCUD CHErK f/rASH N,VD 9Y DATE RECEIVED PEP,tttT a <br />�3� --oo a70 00....-.(67/ ��jo�a gA <br />N <br />