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FACILITY CONTACT N,Me <br /> FACILITY SITE NAME - �9�� A/Q <br /> F T12 4I <br /> A SITE PHONE # with AREA CODE <br /> [ FACILITY ADDRESS © <br /> �� �Q rel ���� 0"q' 9ez <br /> # of TANKS <br /> I S� 'I UTE 2IP -Z3 at SITE <br /> T CITYCi�IG (� / L [(�' <br /> Y APPLICANT CONTACT NAME <br /> r <br /> AAPPLICANT/BILLING NAME 17 T�FI <br /> P <br /> LAPPL[GANT PHONE * WITH AREA CODE` <br /> I MAILING ADDRESS 7 /1� L-OZ r �b I �,c� <br /> C 7 ! "[/ CJ ! TYPE of APPLICATION V V/NO o �— <br /> A STjTE 2IP CODE <br /> N CITY V7n� s. 7 [ 5�,1 CLOSURE, INSTALLATION, etc. <br /> T J�/✓ ( t/ <br /> TOTAL <br /> 1986 1987 1988 1989,;, 1990 <br /> A <br /> C 5 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 <br /> I 1, 1991) <br /> V rior to January 1,1491) $170/TANK (after January <br /> E TANK FEE a 35).00/TANK (p <br /> F 0 Tanks 19'86 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 $ <br /> A (multiply # by fee for <br /> C each year applicable) Section 25287 <br /> ! ears) See 'Callfornis H L S Code, <br /> L STATE SURCHARGE C $56,00 each TANK (Due every 5 Y 1991 through 1996 <br /> ! 1986 through 1990 <br /> T # Tanks x 556.00 5 <br /> Y (enter amcxnt and year) <br /> Place) TANK I.D. <br /> PERMANENT CLOSURE (Removal or Authorized CLosure-in- #(s) x 5159.00 <br /> C r TANK) # TANK(s) <br /> L CLOSURE FEE w $53.00 per hour (3 hours minimum per <br /> 0TANK I.D. #(s) <br /> nsp <br /> S for review/iections) <br /> U TEMPORARY CLOSURE (A one-time permit, 5 <br /> # TANK(a) X !150.00 <br /> R ■ <br /> E TEMPORARY CLOSURE FEE = 1150.00 each TANK <br /> P PLAIT CHECK (Install. P(an Review A Construction Inspections) TANK I.O. #(s) <br /> L 5 <br /> 5424.00 minimum <br /> _ <br /> N PLAN CHECK FEE - $53.00 per hour (& hours minim.m pe <br /> Inspections) TANK I.D, #Cs) <br /> R REPAIR FEE (workplan review $ construction x $154.00 $ <br /> E # TANK(s) <br /> P TANK REPAIR FEE w 553.00 per hour (3 hours minimue/TANK) <br /> A = $159,00) =S _ <br /> 1 r hour (3 hour mini" per facility <br /> R PIPING REPAIR FEE = 553.00 per <br /> H CONSULTATIONS UNAUTWOR12ED RELEASE EVALUATION SAMPLING INSPECTION <br /> FEE 5 53.04/hr <br /> S FEE = S53.00/hr / <br /> C FEE = $53.00/hr TOTAL DUE $ k, <br /> OFFICE USE ONLY » ', CTN&v M" <br /> a ....W.. .G•.:_®{�... { ... �,......... aAY1YwrlallalwwlP� <br /> .... .........�... ww iww 10 ow� <br /> ve.aw <br /> �AW lIrwN <br /> » ...••••...••.••-....• ieM i�wir+w»ws>•w»ww ew av Wall alN Mww lIM1/f1lii NplI IIIA <br /> li.........................o..a veil lww�l�K iYMK f1M�1wO NIMH lIM llwlli M)lNwf lw� <br /> ■Pf A"~alvei PINK AW JwWi NANO fNill�IAM <br /> Paae 11 <br /> EH 23 032 (REV 1/10/911 ft <br /> r j' <br />