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�. JUAUUIN LUUAL MLAL111 V1blKlUl <br /> UNDER UND STORAGE TANK PROGRAM FEE WORKSHEET ` <br /> F FACILITY/SITE NAME FACILITY CONTAC*Co�� <br /> L ST EET DOP,ESS SITE PHONE I NITH AREA CODE <br /> �y ( c, ' <br /> Y CITY ��TQATE ZIP' CODE I of Tanks <br /> Y �� U at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NMtl E " <br /> f0 <br /> P W eslz� {l�fi <br /> �_ ems...... -----....... V-�...c4. ....._...... - ' '-- - - <br /> I MAILING ADDRESS _ APPLICANT PHON I NI TN AREA CODE <br /> k CI TAE ZIP CODE TYPE of APPLICATION (" <br /> T CLOSURE, INSTALLATION, ETC. e <br /> -- — — — --- _g. c� ------------- + <br /> FACILITY FEE = 000.00i each SITE ADDRESS per YEAR TOTAL <br /> ----------------.._...- .._.-_....._..-._.........-........._..._........._.......-_............_...._........_.........- - - ------ -_— <br /> A ' is <br /> 1387... ._..._..._1988---..-._..---1-3 <br /> ........... <br /> ---- -----'---'-S� V. <br /> E TANK FEE = $50.00 each TANK 4 • <br /> - - -- - - .._._..........................................__.....-................_........8....-----.._..........._..._............. ---- - -- -- <br /> F I Tanks _ x 550,00 1396 1987 1988 1589 <br /> A (multipl by fee for - - - -... - ..... ----- --- — <br /> C each year appluable? S <br /> _____ _._ _: .. <br /> L STATE SUP,CHARGE = 556.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> T { Tanks : z f56.0U 1996 1981 1988 1983 <br /> Y (enter mount and year) - "----------- <br /> -- ---- -- ----------------- _-..... .-............ ............---__-- --_ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE = $90.00 each TANK I I Tanks<� z 590.00 f , <br /> S - <br /> I '. <br /> U • <br /> P, TEMPORARY CLOSURE (Only allowed one tine for up to two years) <br /> E -------- - - - - - - .._..._.. - ----- --TEMPORARY CLOSURE CLOSURE FEE = $80.00 each TANK I I Tankss 190.00 f <br /> - - — -- - - ._.......---------- <br /> fP PLAN CHECK (Installation or Repair) <br /> L ------........._........ ..... - .... - ..._.. -- ..-........... -- -- - --- r <br /> A <br /> It PLAN CHECK FEE = S30,00 each SUBMISSION/RESUDMISSION S <br /> REPAIR <br /> R TANK REPAIR FEE = $110,00 each TANK I Tanks __ _ z SIl0.0U S <br /> E -----_ - .. ..................i .-.- ..... _.. ..._...............--- - - --- <br /> P ---- - .-...- --... ------------ <br /> A <br /> ----A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) - _ <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION j <br /> (vhen applicable) (when applicable) (vhen applicable) <br /> ---- - ..._._.._.._.,......-- ..... ............. ......... <br /> . <br /> _ -- - .-..-......__ — <br /> FEE = $30.00/hr FEE -.535.00/hr FEE = $35.00/hr <br /> - - ------ .._..L......----......__.................-...-.............'.. �_-.._...------- <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> @�9W1V1WW11 1111I�V1V9@11IIIW111111flPIN1111�1111!11111N Iu91 !1110111W11!111111111iMIW1 <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT P.CVD CHECKKI/C,ASH RCVO BY DATES RECEIVED PEP.M[T t <br /> Nz� p '��'TlW 911 ' V SII^IIVI!.V41@il�A�1V!9 9111WiIIIII�iIW1119VIIIIIVIIIVG INIV W IVI illi <br /> i <br />