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UOROUND STORAGE TANK PROGRAM FEE WORKSHEET* <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C <br /> I SITE PHONE Y (with Area Code) <br /> I STREET ADDRESS 232 Y ��/%STAT]E <br /> T 21P CODE �fTANKIS nY CITY <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> C— E E <br /> L APP (CANT PHONE Y (with Area Code) <br /> 1 MAILING ADDRESS _ Z <br /> C �' L <br /> A STATE 21P CODE TYPE of APPLICATION G4-0509-t"� <br /> N CITY i (Closure, Installation, etc.) <br /> T <br /> FACILITY FEE = S100.00 each SITE ADDRESS per YEAR TOTAL <br /> A1986 1987 1988 1989 <br /> C <br /> �oU f l C) <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks 1 $50.00 1986 1997 1988 1989 <br /> A Iultipry by fee for $ I <br /> C each year applicable) 1 00 <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK. (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> T t Tanks 1 556.00 1986 1987 1988 198'3 <br /> Y (enter aaouat and year) S <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> LY Tanks_-� z $90.00 $ p <br /> 0 CLOSURE FEE = $90.00 each TANK <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> EY Tanks 1 $80.00 $ <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK <br /> P PLAN CHECK (Installation or Repair) <br /> L MAK <br /> A S <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br /> R REPAIR PERM <br /> E TANK REPAIR EEE _ $110.00 each TANK Y tanks_____ 1 $110.00 S <br /> P <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 FEE _ $35.00/hr $ <br /> TOTAL DUE <br /> OFFICE USE ONLYI logo= <br /> � <br /> SWEEPS t COMP 1 LOC CODE D[ST CODE AMOUNT DUE AMOUNT RCVD CHECK t/CASH RCVD BY DATE RECEIVED PERMIT t <br /> .738V FSIEa �'Sd D- fk 3//t' o <br />