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OHIN J UMU'l-) 1N LU -ML NLAL- 1 1-1 J i b i K I G I <br /> UNDERr"'INID STORAGE TANK PROGRAM FEE WORKSHEET <br /> .......... ------- <br /> F FACILITY/SITE NAME <br /> w. <br /> C 14/ jjg��7C/ j4.4nC^ <br /> -H-d-04....... ............. <br /> STREET ADDRESS SITE PHONE N WITH AREA CODE <br /> CITY STATEl', ZIF* CODE of- <br /> at Site e) <br /> ---—------------------------------------ICA— -T ll--..--,-.-"--",....—.---,.....----.- <br /> A APPLICANT/811-LING NAME APPLICANT CONTACT NAME � I/ loeSSIC,L <br /> PWeJ�7-eA�l MMC f, S e-w-Vic6i /"e- <br /> P <br /> L - C) r e6d <br /> --------- ............. ... ................. ....... I-j tq-ck z' tt— <br /> �------------- <br /> I MAILING ADDRESS APPLICANT PHONE I WITH AREA CODE <br /> A <br /> N CITY STATE z I P"C"ODE n'DE -f APPI IrAYJON <br /> IH�T�I,"AT'10:4, ETC. <br /> -t-o c-1(4—v,,h <br /> ................... ................................. ------ <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> ............. <br /> C1 I-1386 1-387 INS 1 8 1 <br /> T .............. ...........—- ....... ---------------- <br /> -------- <br /> ETANK FEE $50,00 each TANK <br /> I - - .. ........ <br /> I Tanks 1,3,7 <br /> v <br /> -I-bl 'JI-10 1,31, 981 <br /> A (multiply y fee for ......... <br /> each year applicable) <br /> I ..............-........ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> . ...... ................... <br /> I Tanks x 556.00 SS <br /> keirfer a6jiliit and ye ar) <br /> ---------------------------------------- ........... ............ <br /> ...........- 1..-.-I-1.................. ....... .................. <br /> PERMANENT CLOSURE (Renuyal or Closure-in-pjare) /vi 0 Vf 4, <br /> 0 CLOSURE FEE = $90.00 each TANK I Tanks <br /> J <br /> ---] --. , 0 <br /> L ------- .......... <br /> L <br /> a <br /> S <br /> ................................. -- ------------ <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E ................I----------I--........................ <br /> TEMPORARY CLOSURE FEE = $80,00 each TANK I Tanks x 190.010 <br /> .. ........ ........ <br /> .............................. ................................. -------------- <br /> P PLAN CHECK (Installation or Repair) <br /> L ................. ....................... ....................-........... <br /> N PLAN CHECK FEE = $30.00 each SUPMISSION/RESUDMISS[011 <br /> ----------------- <br /> FFF—EPAiR ----- ------------- -- <br /> ..........................- .......................... ----------- --------- <br /> R TANK REPAIR FEE = SIIO.00 each TANK I Tanks x 1110.00 S <br /> E ... . ....... .............. .77.7.7 7---... ........... <br /> ........................ ------ ---- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid or. plan submittal) <br /> ----------------------- ------- <br /> R UNAUTHORIZED RELEASE EVALUATION JCONSTRUCTION' INSPECTION SAMPLING INSPECTION <br /> (when applicable (020 appllcable) (when applicable) <br /> FEE3FEE. 3 -.0 0/h <br /> EEE �1�00.:00/�r _- ' 00/h I - '-'- <br /> TOTAL DUE 0, 0 <br /> OFFICE USE ONLY <br /> 0 MEN1111110111119101 'M <br /> SWEEPS I COMP I L0: CODE DIST CODE AMOUNT DUE � AMOUNT R-CY-D CH E I P 11 K I A.,S-H 1,'11 C.11 Y-D.1-1.BY- DATE R ECE I 7E <br /> j U R7 � <br /> !1P! .1 j H NMI Mp I I g1l I 1� <br /> MR1, <br /> - <br />