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IE vgKEt alum8f TANK PRO&RAM - <br /> A` <br /> FEE IfORKSNFFT <br /> • L STREET ADDRESS U 1 � ' FACILITY CO ,MAKE <br /> T M oil ` } bV41 TrL £� <br /> Y CITY a SITE PHONE I (with Area Code) <br /> A APPLICANT/BILLING NAM STATE P CODE # of TANK'S <br /> P <br /> P - 3 {� at Site <br /> L U{ APPLICANT CONTACT FLAKE <br /> I MAILING ADDRESS <br /> c 1 Oil <br /> A <br /> N GlTY nn APPLICANT PHONE # (vith Area Code) <br /> STATE 1 CODE - TYPE of 3 X f ®1 . r <br /> FACILITY FEE - ��-33 � (Cl osurepPlnstal]a#ion <br /> ION <br /> A $100.00 each SITE ADDRESS , etc.) � � <br /> Per YEAR <br /> T1986 <br /> I 1987 <br /> v1988 1489 TOTAL <br /> E TANK FEE = $50,00 each TANK <br /> F # Tanks s <br /> 00 <br /> A (�rulti T-- - .r fee fo 1986 <br /> C each year applicable) 1981 1988 <br /> I 1989 <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH i SAFETY CODE Sec <br /> I # <br /> T I Tanks z $56.00 25287 for applicability) <br /> Y (enter mount and year) 1986 1981 <br /> 1988 1989 <br /> C PERMANENT CLOSURE (Reooval or Closure-in-place] $ <br /> L <br /> O CLOSURE FEE = $90.00 each TANK <br /> S <br /> U # Tanks - x $90.00 <br /> R TEMPORARY CLJSUR°E (Only allowed one tine for ap to two years) <br /> E <br /> TEMPORARY CLOSURE FEE -- s80.00 each TANK <br /> # Tanks __-- x 180,00 <br /> s <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = '20,00 PJch Sl1B1lISSION/RfSUgMlSSION <br /> REPAIR : <br /> P <br /> E TANK REPAIR FEE = s110,00 each TANK <br /> P <br /> A # Tanks _ x 1110.00 $ <br /> I PIPING REPAIR/CLOSURE/REMOVAL {Fees are per hour, minieua one hour to 6e paid onIan s <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION P ubaittal) <br /> (when applicable) INSPECTION SAMPLING <br /> FEE = 130.001'hr INSPECTION <br /> FEE = $35.00/hr FEE = $35.00fhr <br /> s <br /> OFFICE USE ONLY TOTAL DUE $ 0 F <br /> SWEEPS $ COd1P # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH <br /> RCVD BY DATE RECEIVED PERMIT # <br />