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A„ 3riry , gn;���'.'�^TF3+.: t rr} ..{_ PYA ll.L5 K i U <br /> UN( '"RGUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> r4 IILIT,Y/SI"E 11AME PCICITY COIITAAMC -----�� <br /> .�E�USGL�aM._._.-Scy. -01......._--..................... V✓ESTL�2rt N1STa�t 6�Rvree3� fuc <br /> L STRtcT-ADDRESS SITE PHONE k WITH AREA CODE <br /> IT ail yDv S lL'11�Tl�,_ _..._.._.. -.... ........_..__.._..__... - a_( ._�._.... 5'-2s 9Z <br /> 1TY� STATE 71P CODE 1 of Tanks <br /> at Site <br /> A 1111­11AITIIII-INGT t1AME APPLICANT CONTACT NAME <br /> F V✓IIIW-.l'7-epMN /'XPi Mft SP.w-" � 114G . v r <br /> J <br /> L <br /> --- — — --------- .._ _ _ . <br /> .._...... .._... ..._ .. ._............... ------._._. - -- .._..._ <br /> I MAILING ADDRESS APPLICANT PHONE I WITH AREA CODE <br /> r <br /> K CITY STATEI 2IP I ODE I TYPE of APPLICATION <br /> TCLCauRE INSTALLATION, E;c.n <br /> r< es�n - 1S?4s�. -I ....._ .... _ .__ . ICEMU6�A <br /> -- - .._... _....__. ...... - -- – -- <br /> FACILITY FEE = S100,00 each SITE ADDRESS per YEAR TOTAL <br /> T 13Gc .,..-_ 13'7 1989 !983 <br /> C TANK FEE = $50.00 each TANK <br /> F 1 Tanks _ _ s 550,00 136 98 i83 <br /> AI(ioltipTy f by fee for -_—� <br /> C each year applicable) { S ti I <br /> J . _ - ._.. - ------._._� — <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) 9m <br /> 1 -- - .. _ - --- - <br /> i <br /> T 1 Tanks x nd yea <br /> 356 81 995 J 8i ENS 70 MENS r(I EALT <br /> Y (enter aeount and years __.. _ __. I _ . .__ P-€�j7} <br /> .j <br /> ._... - . . . .... -. -_ . .--------------- <br /> ..... ..._ -..._ .. <br /> L CLOSURE <br /> . _ <br /> CFEPMANELOSUPE0( <br /> ECkenoval or II>>ure in pIa el <br /> 0 CLOSURE FE = S3 .00Tanks__,?- <br /> ..---_- <br /> "------ <br /> each TANK I Tanks � - s 130 0 f O <br /> U — ---- -- -- - _...._.__._._._...._.... -..... <br /> ...-- ---- <br /> F TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E ---- _. - --— <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK. I k cans, s 180.00 f <br /> _ - -- -- _ ... _ <br /> hPLAN <br /> CHECK (Installation or Repair) <br /> - - . ..... .. _...._. ... . ... - - -- <br /> I[ NCHE <br /> NPLACK FEE = $30.00 each SUBMISSION/RESUBMISSION - f <br /> IREPAIR __.........-....................._..__............__..._._._..._._..------... ------ - - ---- t <br /> F. TANK REPAIR FEE - (110.00 each TANK It Tan';s 5110.00 f <br /> E <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I -- ------ --_.._.....__.-.--------.._..._...._.._.__.._.._........_....._..-----_.___..........._.......----------------- <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> —— — --- <br /> FEE = 530.00/hr FEE 35 UO/hr FEE 3 00/hrl _— S -- <br /> TOTAL DUE S J 0-6 <br /> OFFICE BEE ONLY <br /> im�, �! � :a: . �q�G��u! �Qgl!fdl fl?�Ilgk!�1QQ8tlQIIgi191QIIgBgf�qqllBqllQqlll!IlQfllll!'ll�!II!illggiilll!gql!IIiIQII!!I!u!I!iIfIQQQlgililfll!QIQIfIIQIIQIIgQC41Qll!IIIIIIIIGIIIIIIQQIIPVQIIgfIQ�QQgQIIQgqflQVIVIqQIQ�QOQqI. IiE'V!9®I�lq�a"�&" <br /> . G . <br /> SWEEPS I COMP 1 LO CODE DIST CODE AMOUNT DUE AMOUNT R'YD CHErk q/GASH RCVD 9Y DATE P.ECE[VEO PERTi t <br /> J1 R. B .Tr �gl6QP9QrQgV,.f9Qlal9?flQl!?IVh! nulgQQQ!IIQ!!IIIIIILgIp;l!I'I,Q!!II:�gIQQ9!h!ills!!IQi!!QIIIIIIy!Ilgq!I@lggfll!!Illlgq"VIIIVtl( gV':.19Q9V'IQ ,.!.:kQiIJQgQ 1.�� 113Q3s <br /> new J-je 3 / <br />