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�4—eiL. 1-1QiL 1 i1 L . 1 1�1 4 1 <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WO ET <br /> 1 <br /> C F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A � / <br /> Lr <br /> I <br /> L STREET ADDRESS SITE PHONE I (with Area Code) <br /> T <br /> YCITY <br /> &'q/ <br /> �� STATE IIP CODE I of TANK'S <br /> at Site <br /> A APPLICANTIDILLING NAME APPLICANT CONTACT NAME <br /> P <br /> I MAILING ADDRESS _ APPLICANT PHONE 1 (with Area Code) <br /> N CITY STATE I1P CODE TYPE of AP <br /> 1 , / Q jI-- 5 z� (Closure lnsta lation etc.) <br /> FACILITY FEE = i100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 190G 1981 1988 1989 <br /> T <br /> 1 $ <br /> V <br /> E TANK, FEE = $50.00 each TANK <br /> F I Tanks x $50.00 19OG 1981 1980 1999 <br /> A (eultipTy"l-by fee for <br /> C each year applicable) f�� O <br /> L STATE SURCHARGE = $56,00 each TANK. (see CA HEALTH 6 SAFETY CODE Set 25201 for applicability) <br /> I <br /> T I Tanks x $56.00 1?8G 1981 1908 1989 <br /> Y (enter daoUt and year) <br /> C PERMANENT CLOSURE (Reaoval or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90,00 each IANK I Tanks x $90.00 $ <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tine for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80,00 each TANK finks _ x $80.00 $ <br /> P PLAN CHECK (Installation or Repair) 2� <br /> L <br /> N PLAN CHECK FEE = $30,00 each SUDMISSIONIRESUBMISSION1i� F ! �`► , $ 2U.co <br /> REPAIR <br /> R <br /> I: TANK REPAIR FEE _ $110.00 each TANK r ,$ Tanksx $1[0.00 $ <br /> P <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, iinirua one hour to be paid on plan suhaittal) ----� <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION ,. SAMPLING <br /> (when applicable) INSPECIION INSPECTION <br /> FEE = $30.001hr FEE _ S35.001hr FEE $35.00/hr $ <br /> TOTAL DUE S ��! <br /> OFFTCF USf ONLY <br /> 31 <br /> SWEEPS 1 ICOMP -1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECY, 1 ASIC RCVO BY DAIE RECEIVED PERMIT 1 <br /> 121-7-- ' Q <br /> � 2:?-� <br /> i W14 <br /> � � <br />