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. ��,� S,/E�f2 ,�p� FACtIITk CONTACT HANE �`'� <br /> L STREET ADDRESS <br /> LI <br /> 3 t3hGt�.9 SITE PHONE 1 With ky Cods) <br /> Y CITY <br /> S%OC Ml j STATE lip CODE 1 of T1 <br /> A APPLICANT/BILLIN6 NW J at Site S I� j00 Ey(�pC/ <br /> PG'O APPLICANT CONIACT NAME <br /> L � T OcS <br /> I nAll[N6 ADDRESS <br /> IN CITY �l � � APPLICANT P I WithAT— <br /> T ODESTo �E 11 WOE � TYPE of APPLICATION <br /> A S <br /> 500 (Closure, Installation, etc.)�LU <br /> (AGILITY FEE /100.00 each SIZE ADDRESS per YEAR <br /> T <br /> TOTAL <br /> 1986 1987 1988 1989 <br /> V <br /> E TANK FEE = 150.00 each TANK 1 <br /> F ranks 1 150. 0 <br /> A ,multiply I-by tee /or 198h <br /> 1987 1988 1989 <br /> C each year applicable) <br /> I <br /> L STATE SURCHAkGE _ {56.00 e11 a11 cII h I.TANK (cite CA NEALIN 1 SAFETY CODE Sec 25287 for applicability) / <br /> I <br /> T 1 Tanks s $56,0( 1986 <br /> Y (enter asount and year) 1981 1988 1989 <br /> • f <br /> C PERMANENT CLOSURE (Reeowal at ClosartA-p1acU <br /> L <br /> 0 CLOSURE FEE = 690.00 each TANK <br /> U <br /> S 1 Tants _ : {90.00 <br /> E TEMPORARY CLOSURE (Only allowed one tiw (or up to two years) <br /> TEMPORARY CLOSURE FEE = 160.00 each TANK <br /> 1 {ants ___ r f80.00 { <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ /30.Dp each SUBMISSION/RESUBNISSION <br /> S <br /> REPAIR <br /> P. <br /> E TANK REPAIR FEE Is 1110.00 each TAM <br /> 1 {ants_ __ : (110.00 f <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, einiew one hour to be paid on plan wbeittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION <br /> when applicable) INSPECTION SAMPLING <br /> FEE = 630.00/hr INSPECTION <br /> FEE m 1135.00/1ir FEE + $35.00/hr <br /> f <br /> OFFICE USE OaIY TOTAL OW f ?Q <br /> SWEEPS 1 COMP 1 LOC CODE Illi CODE AMOUNT OUE AMOUNT RCVO !CHECK -/CASH RCVD BY RATE RECEIVED PERM){ 1 <br /> • <br />