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4UAwU1o4 LwGtiL HGMLirt L161Kal. 1 <br /> WRGROUND STORAGE TANK PROGRAM - FEE WORKSH <br /> F FACILITY/SITE NAME FACILITY CO FET NAME <br /> T AM <br /> C �� ✓ V[ <br /> I <br /> L STREET ADDRESS �3`1 y zaj✓� SITE PHONE i (with Area Code) <br /> T <br /> Y /14P Nar <br /> CITY STATE ZIP CODE t of TANK'S n £ �f <br /> r 1�G at Site <br /> (/ <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L — — £ V <br /> 1 I MAILING ADDRESS APP ICANT PHONE t (with Area Code) <br />+ N CITY STATE TIP CODE TYPE of APPLICATION C A-0SO 415'i T i (Closure, Installation, etc.) <br /> T <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> E A <br /> k C 1986 1987 1988 1989 <br /> I <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> f. F i Tanks � x $50.00 1986 1987 1'988 1989 <br /> A (multiply 1 by fee for <br /> C each year applicable) <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks_____ounx $56.00 1986 1987 1988 1989 <br /> Y (enter amt and year <br /> $ <br /> i <br />! C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 1 L <br /> 0 CLOSURE FEE _ $90.00 each TANK t Tanks x $90.00 $ 'p <br /> S - <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> f TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks____ x $80.00 $ <br /> f P PLAN CHECK (Installation or Repair) <br /> A MAN 1y,7 <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR =_FI1AL IR <br /> PERM <br /> rrR <br /> E TANK REPAIR FEE = $110.00 each TANK t Tanks x $110.00 $ <br /> A <br /> 1 PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R 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 ONLY O <br /> L-73Pt? <br /> 1 COMP i LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED PERMIT 1 <br /> Lrs7i a a =11 <br />