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1 — _ _f" <br /> J., <br /> DfRGR00 ST `W�fvL NcgL1N ll YRIC1' <br /> f FACILITY/SITE NAME UHORAGE TANK PROGRAM - <br /> A FEE NORKS <br /> C Fu 1 Ge,- <br /> L STREET ADDRESS <br /> �(o bi le crn <br /> Ne FACILITY CONTACT NAME <br /> 1 <br /> 1 v <br /> Y CITY LOU SITE PHONE 1 <br /> wlin •nc� Co.,, <br /> A APPLICANT/BILLING NAME CH STAT 11P CODE 1 <br /> P of Tanks <br /> P at Site <br /> CL APPLICANT CONTACT NAME <br /> MAILING ADDRESS <br /> A <br /> NCITY <br /> 1 APPLICANT PHONE i v�*n �. coom <br /> STAT 11P CODE iYPf of <br /> FACILITY FEE _ «u.u.r,AP.P,iiCATIDHon <br /> A $100.00 each SITE ADDRESS mrc. <br /> C ° Per YEAR <br /> r <br /> 1 1986 1987 V 1988 TOTAL <br /> E TANK FEE _ � <br /> $50.00 each TANK 1989 <br /> l tanks <br /> A r (50.00 <br /> A It 1.00 fee for 1986 <br /> I each year applicable) 1987 1908 <br /> U 1989 <br /> L STATE SURCHARGE = <br /> 1 156.00 each TANK (See CA HEALTH 6 d <br /> Y 1 Tanks _ a $56.00 SAFETY CODE Sec 25207 for a <br /> Y (enter amount and year) 1986 DDlicability) <br /> 1987 1988 <br /> Z� 1909 <br /> C PERMANENT CLOSURE (Removal or Closure in <br /> L _ $ <br /> 0 CLOSURE FEE o $90.00 p—e) <br /> S each TANK <br /> U 1 tanks 2 <br /> R TEMPORARY CLOSURE (Only allowed one time for -- Y (90,00 <br /> E f I o0 <br /> TEMPORARY CLOSURE FEE - uP to two each TANK years) <br /> P PLAN CHECK (Installation or Repair) I Tanks__...... r $80.00 <br /> L f <br /> A <br /> N PLAN CHECK FEE = (30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR f <br /> R TANK REPAIR FEE _ $110.00 each TANK <br /> E , <br /> P 1 Tanks_ - _ (110.00 <br /> A PIPING RCPAIR/CLOSDRfiRfnOVAI Mees are $ <br /> I <br /> UNAUTHORIZED RELEASE EVALUATION Per hour, minimum one hour to be <br /> Iwhen applicable) CONSTRUCTION INSPECTION paid on plan submittal) <br /> FEE _ $ 0.00/hr (when applicable) SAMPLING INSPECTION <br /> EEE _ (75.00/hr (vN— en applicable) <br /> EEE _ $35,00/hr <br /> DFf1Cf USf ONLY $ <br /> TOTAL DUE <br /> S LOC CODE DIST CODE AMOUNT DUE <br /> AMOUNT REVD CHECK I/CASH r y <br /> Fru LLE � �- 32(� �- REVD BY DATE RECEIVED <br /> PERMIT 1 <br /> ---'— <br />