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*GROUND STORAGE TANK PROGRAM FEE WORKSHEE10 <br /> " F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> jI SITE PHONE I (with Area Code) <br /> STREET ADDRESS 23 2 Y vle- <br /> TSTATE 2IP CDDE Y of TANK'S �J <br /> Y CITY at Site <br /> �c <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P ' G , G 6 E <br /> L APP IC) PHONE I (with Area Code) <br /> 1 MAILING ADDRESS % _ Z <br /> C .L ZD:n <br /> tc <br /> A STATE 71P CODE TYPE of APPLICATION G/ CJS✓IL>— <br /> N CITY i (Closure, Installation, etc.) <br /> T <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A 1986 1981 1988 1989 <br /> C <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F I Tanks x $50.00 1986 1907 1988 1981 <br /> A (nultiply by <br /> C each year appI cable) / U <br /> 1 <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T I Tanks x $56.00 1386 1987 1988 1989 <br /> Y (enter auount and year) s <br /> C PERMANENT CLOSURE (Reooval or Closure-in-place) <br /> L $ Tanks__ x $90.00 $ O <br /> O CLOSURE FEE _ $90.00 each TANK <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E Y Tanks x $80.00 $ <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK <br /> P PLAN CHECK (Installation or Repair) <br /> L MAN <br /> A $ <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> rk it 11— TAt-REAUTFF <br /> R REPAIR PERM <br /> E TANK REPAIR FEE _ $110.00 each TANK 1 Tanks_____ x f110.00 $ <br /> P <br /> A <br /> 1 PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> RSAMPLING <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE $.540 <br /> OFFICE USE ONLY <br /> SWEEPS t COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT t <br /> 73 <br /> 6'v EFS Ifa YD �'S a a Vim. .)��o <br /> ., a <br />