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JuAwU114 Luc.NL Hr-A " /�) <br /> )ERGROUND STORAGE TANK PROGRAM - FEE WORKSH 11 �� <br /> . F FACILITY/SITE NAME FACILITY C CT NAME <br /> I SITE PHONE I (with Area Code) <br /> L STREET ADDRESS �3 2 y ✓E <br /> i T STATE ZIP CODE 1 of TANK'S <br /> Y CITY �J; at Site <br /> APPLICANT CONTACT NAME <br /> A APPLICANT/BILLING NAME <br /> P �>. 4. C— E ✓ <br /> L APP ICANT PHONE 1 (with Area Code) <br /> C MAILING ADDRESS <br /> A STATE TIP CODE TYPE of APPLICATION CLOS✓�1— <br /> N CITY i (Closure, Installation, etc.) <br /> T <br /> TOTAL <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br /> A I 1986 1 1987 J 1989 <br /> T ` O fr Q � <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F I Tanks _ z $50.00 1986 1981 1388 1389 <br /> A (multiply_I_by fee forb Q' $ 0 0 r <br /> C each year applicable) <br /> L STATE SURCHARGE _ $56.00 each TANK, (see CA HEALTH L SAFETY CODE Set 25287 for applicability <br /> f <br /> T I Tanks_____ x $56.00 1386 1981 1388 1 <br /> Y (enter amount and year) $ <br /> C PERMANENT CLOSURE (Remtallowed <br /> -in-place) <br /> L I Tanks__ z $90.00 $ �Q <br /> 0 CLOSURE FEE _ $90.00 <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Onime for up to two years)E I Tanksz $80.00TEMPORARY CLOSURE FEETANK <br /> -------------- <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A f <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> c <br /> REPAIR <br /> R „ c 1 nn t H, f Tanks x $110.00 $ <br /> E TANK REPAIR FEE _ $ .0.00 each TANK <br /> P <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> RSAMPLING <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTIINSPECTION INSPECTION <br /> (when applicable) <br /> i FEE c $30.001hr <br /> FEE _ $35.00/hr FEE _ (35.00/hr $ <br /> TOTAL DUE $ Q <br /> �ot� oo l� b 89 0 b <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP I LOC CODE GIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BYtLDA1E/1LECETVE1 PERMIT <br /> L3 F0 wrrrA3 01 `dao x2o _ 9a — �5o a- �i2 3/ <br /> 4 <br /> !s <br />