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.. .. v • rvv.Yu- •.r�.VYIY YaYYY\LVI <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> ' ��/�� /�S ZV4& ESQ flu)rj <br /> L STREET ADDRESS / SITE PHONE t (with Area Code) <br /> Y CITYSITE ZIP CODE t of TANK'S <br /> c�Ni' ['�TOn/ (� at Site <br /> A APPLICANT/BILLING NAME APPLLEANT CONTACT NAME� / <br /> /Cf : /� 1vTz7n-)) <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> N CITY /�/J r SJATE ZZp 000E TYPE of APPLICATION n <br /> T / ✓ /G of S %ZJ C./4 ��C12 / (Closure, Installation, etc.) <br /> A FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> 1 f <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F t Tanksx $50.00 1986 1987 1988 1983 <br /> A (multiply_1_by fee for <br /> C each year applicable) $ <br /> L <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T t Tanks x 156.00 1986 1981 1988 1989 <br /> Y (enter aiount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90,00 each TANK <br /> 5 1 Tanks__]__ x $90.00 f �, p 'v <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks x $60.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK <br /> P t Tanks x (110.00 f <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = $30.00/hr FEE = $35.00/hr F FEE = $35.00/hr f <br /> TOTAL DUE is 9(}� <br /> OFFICE USE ONLY <br /> zzju�z <br /> OMP { LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVO CHECK {/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> `ro — �3 �� a a1��9 <br /> u <br />