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.+ rr.-J -64 ,...,..,4ML 1-1"rIL. I ri 1 IC 11. i <br /> JUNDERGROUND STORAGE TANK PROGRAM - FEE WORK IIECT <br /> F FACILITY/SITE NAME / FACILITY CONTACT NAME <br /> A G <br /> ' I ` <br /> L STREET ADDRESS SITE PHONE I (with Area Code) <br /> T <br /> Y CITYSTATE ZIP COME 1 of TANK'S <br /> at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P 9Z <br /> I MAILING ADDRESS APPLICANT PHONE 1 (vith Area Code) <br /> n ~iy Crr l� /,a6 d <br /> /8 <br /> N CITY NSTATEIZIP COBE TYPE of AP <br /> I j �0 �- Z_ (Closure festa latian etc.) <br /> FACILITY FEE = $100.40 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> T 1986 1987 1988 1989 <br /> V <br /> E TANK FEE _ $50.40 each TANK <br /> F 1 Tanks x $50.04 1986 1981 1988 19813 <br /> A (multiply'l-by fee for I ,,,V <br /> C <br /> I each year applicable) I-?)c $ f CSU <br /> L STATE SURCHARGE = $56,04 each TANK (See CA HEALTH 6 SAFETY COBE Sec 25281 for applicability) <br /> l <br /> T 1 Tanks 3 x 156.00 1906 1981 1980 1989 <br /> Y (enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tanks x $90.00 $ <br /> S - - <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tiae for up to two years) <br /> E <br /> TC?SPORARY CLOSURE FEE = $80.00 each TANK .$,Tanks-rff .00 $ <br /> .J <br /> PPLAN CHECK (Installation or Repair) <br /> L <br /> N PLAN CHECK FEE _ $30.04 each SUBMISSION/RESUBMISSION ,SCco�9�yF S <br /> R REPAIR <br /> C TANK REPAIR FEE = $110.00 each TANK <br /> P f Tanks x i1l0.00 $ �— <br /> - <br /> A <br /> 1 PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) �— <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION 7 ,. SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = f30,041hr FEE = $35.00/hr F£E _ $35.00/hr f <br /> TOTAL DUE $ �!dv <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP f LOC COD£ DIST CODE AMOUNT BUE AMOUNT RCVSrc�K)DASH RCVB BY DATE RECEIVED PERMIT 1 <br />