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wmL nu ounnUL IAnA rnuuAnn - ILL ■uAAnnL[I <br /> F FACILITY/SITE NAME <br /> A ` `'''%cj <br /> CONTACT NAME <br /> 1 k� (1 <br /> L STREET ADDRESS <br /> I UC l E 7 ) E 1 WITH AREA COD[ <br /> T \ <br /> Y CITY <br /> c f Tanks <br /> ite <br /> A APPLICANT/BILLING NAME <br /> P CONTACT NAMEPL 1 MAILING ADDRESSA 7!JS <br /> PHONE { 41TM AREA cone <br /> N CITY <br /> T TAT Ej YPE of APPLICATION <br /> CLOBUAF, INBTALLATInN, CTC. I(I <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br /> T 1986 19B1 TOTAL <br /> 1988 1989 <br /> 1 II <br /> V <br /> E TANK FEE _ $50.00 each TANK 3 U U <br /> F 1 Tanks J x $50.00 1986 <br /> A (multipry 1-by fee for 1987 1988 1989 <br /> C each year applicable) S U �— <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see C <br /> I A HEALTH Z SAFETY CODE Sec 15287 for applicability) <br /> T ! Tanks ' <br /> $56.00 1986 1987 <br /> Y (enter mount and year) 1988 1989 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK <br /> S Tanks _ x $90.00 $ o <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> 1EMPORARY CLOSURE FEE _ $80.00 each TANK <br /> 1 n _ x $80.00 $ ,� <br /> P PLAN CHECK (Installation or Repair) <br /> L r <br /> a <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> f '— <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK CFS V r <br /> E <br /> P 1 _ _ x $110.00 $ <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one h �A4_ <br /> I 'V id on plan submittal) <br /> R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION <br /> (when applicable) (when applicable) <br /> (when a'p hle <br /> FEE _ $30.00/hr FEE _ $35.00/hr <br /> $35.00/hr $ <br /> OfffCE USE ONLY TOTAL DUE <br /> SNEEPS 1 CDMP ! LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEI4ED PERMIT t <br />