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A APPh�'NT/BILLIN�nratlr_ -------'. -_- STATE .TLIP CODE I of Tanks <br /> E J y <br /> LIIIO - ------- -- --- ONE (1 ) ; <br /> NAMF APPLICANT CONTACT NAME lE, <br /> P !! <br /> WESTERN <br /> L , �13D1_NIETER_$FAR.Y..�CE___•_.,___ WILLIAM F. MESSICK <br /> I MAILING ADDRESS - -- -- <br /> 1. APPLICANT PHONE 1 WITH AREA CODE <br /> 1 d FE_.R$1-V-E...5M. E._ _ (2. 0.9)vR948-6124 DR ETC. REMOVAL <br /> CITY STATE IIP CODE TYPE of APPLICATION <br /> __ _ -_- - -1 -_-_-__--__- <br /> ON _ CA. 95205 <br /> I — --- 1986 p--............... <br /> 1'...... . .. 1988 _. -- — - - --AL ` <br /> FACILITY FEE - $100.00 each SITE ADDRESS per YEAR _ _ TOTAL <br /> A - <br /> T I 1983 <br /> - - _- ....... .. --------- <br /> I -- )' <br /> --.-_.._........ _---------._...........-�-_.._ --J..-._ _---- .-__- I . <br /> E TANK FEE = $50.00 each TANK <br /> —----- _..._ -- ----............. .....-..--... -- r <br /> F I Tanks _ _ x $50.00 1986 1981 1988 t9B9 I 1 <br /> A (multipTy 1 by fee for _ <br /> C each year applicable) F <br /> I = - ----- ---- - — - ._.-� ---- <br /> L STATE SURCHARGE $,6.00 each TANK (see CA HEALTH b SAFETY CODE Sec 25287 for appIicp�&10HEALTH3ERVICES I <br /> T I links x $56.00 1986 1987 1988 138'3 <br /> ---- f <br /> I. Y (enter mount and <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE _ $'30,00 each TANK I Tanks__ x $90.00 t d <br /> S fO t� <br /> ➢. TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> 1 Tania $80,00 <br /> -- _ <br /> iEMPORAP,Y CLOSURE FEE = $80,00 each TANK f <br /> - - - ' <br /> P PLAN CHECK (Installation or Repair) <br /> L ---- -----_- ''- - - ......___..................--... <br /> _-..-- -- -- --- <br /> A <br /> (N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR / <br /> P, TANK REPAIR FEE = 1110.00 each TANK ---- !�( <br /> II Tanks______ x $110.00 $ <br /> E - - --- - ---_- _ ... - ._.......---.-............_ <br /> A PIPING REPAIR,/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED P.ELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = $30.00/hr FEE $3,,.00/hr� FEE _ $35.00/hrf $ <br /> ..................._._. .._ <br /> TOTAL DUE $ '' <br /> OFFICE USE ONLY — <br /> NWQI� I Munn IIIQNQCQQQQQQQQQQ QI�QQQQIIIIQQQNIIIII!IflIQVQ IQIIQ!QQIQIIQQQQIIQIIIIIIQIIVIINI!IQIIiIQIIQQQQQIQIGIIQIIQQQQIiIIQIIIIIIIINQQIIQIIVIINGIIQIQ QVIQQQQQ�VIID�QQ919 <br /> SWEEPS f COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVB CHECK /CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> 0Q119SHE fCiNQCQN!IIIQNQ4NIIQ N!I�JNQQ@IQQIINQ1SNI Mimi IIQNQQQIV191111QdIIQlll91 UQ BQ 1NI��IQI�1 1.1111ull @II�� <br /> fFN`yY <br />