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SAM J UAUU 1 iV <br /> ET <br /> UNDE NO STORAGE TANK PROGRAM - FEE 9ORKSHE. <br /> FACILITY CONTACT <br /> FACILITYISITE NAME <br /> A 57 %,5 Q-ru 0 <br /> C 51TE PHONE I W11" ARu ea a <br /> STREET ADDRESSO? q' <br /> � �� ` <br /> I r �: I of Tanks <br /> sW C;c IIP C006 it Site <br /> Y CITY Gd <br /> APPLICANT CONTACT NAME <br /> A APPLICANT/BILLING NAME /V19v k 6 Ij /,r... <br /> P � <br /> APPLICANT PHONE I NIT" AREA CODE <br /> I MAILING ADDRESS <br /> C ec, ZCODE/ �l <br /> �A ^� TYPE of APPLICATION <br /> CLO NRLI IMaTALLAT IO"1 LTC. t U <br /> clrY c,n <br /> T TOTAL <br /> FACILITY FEE = 1100.o4 each SITE ADDRESS per YEAR <br /> A -------— 1937 1989 Bel <br /> C 1986 1 <br /> T <br /> V �— <br /> E TANK FEE 154.00 each IANK 1988 1999 <br /> : 1986 1991 1-------— o <br /> F I Tanks 04 <br /> _� 150. 1 <br /> A (ault(piy f-by lee for <br /> C each year applicable) <br /> 1 <br /> L STATE SURCHARGE = 156.00 each TANK (See CA HEALTH i SAFETY CODE Sec 25181 tar la�p831icability <br /> 1 1186 1981 1988 q r->T I Tanks_-- L $56.00 <br /> Y (enter aao�_nt and year) <br /> C PERMANENT CLOSURE (Reaoral or Closure-in-place) <br /> L : 190.00 each ��G I Tanks_ ,(.x)(30.00 <br /> . CLOSURE FEE TANK ~• - <br /> H Iva ears) <br /> P. TEMPORARY CLOSURE (Only alloyed one tiae lot up Y <br /> E <br /> TEMPORARY CLOSURE FEE = 180.00 each TANK NrI` ,.r_ • _------�---- <br /> P PLAN CHECK (Installation or Repair) <br /> L i <br /> A <br /> N PLAN CHECK FEE : $00.00 each SUDMl55TON1RESUCMT5SIO11 _ <br /> REPAIR x . 1 <br /> ... . _ I Tanks------ 1100 <br /> 10 10.00 �----- <br /> R TANK REPAIR FEE = 1110100 each TANK � !—T ---- <br /> E <br /> F <br /> A PIPING REPATRICLOSURElREMOVAt (Fees are Per hour, r�iniaua one haul to be pard on pIT10Nan ubarttal} <br /> 1 SAMPLING 1115PEC <br /> R UNAUTHORIZED RELEASE EVALUATION ONSTRen appl�cablejECT10N (vhen applicable) �� <br /> Nhen applicable) -�—.---- —"E35.0�1jbr _-- <br /> % <br /> FEE $35.0�llhr FEES Q L) <br /> FEE _ $30.40rhr TOTAL DUE 1 � <br /> OFFICE USE ONLY <br /> y l �llaL <br /> i <br /> E DIST LODE AMOUIIT DUE AMOUt{T RCVD CNECK IlCASH FCV� D DY DATE RECEIVED PERMIT 1 <br /> I $ COD <br /> ;I SUEEPS COMP LOC <br /> t • �;� r VEL �L l ���• <br />