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_.. � .,...�_ .. ...,..Vn�. 1'I G nL I n lJ l :.i I K L <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORK* <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> �GcJcG31l — /lifi� �e �- Z/E <br /> L STREET ADDRESS SITE PHONE I (with Area Code) <br /> T / 70 -ds5 3 -e2,-7 <br /> Y CITY STATE IIP CODE 1 of TANK'S <br /> 112.�G U• 3 at Site <br /> AA APPLICANT/BILLING NAME L APPLICANT CONTACT NAME <br /> P Klr� !/ Jt/ > <br /> L <br /> 1 MAILING ADDRESS APPLICANT P NE 1 (with Area Code) <br /> N CITY STATE IIP CODE . TYPE of APPLICATION <br /> T US 9S�'j_ (Closure, Installation, etc.) <br /> A FACILITY FEE = 1100,00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> I f <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks x $50.00 1986 1988 1989 <br /> A (multipfy I-by fee for <br /> C <br /> each year applicable) $ <br /> L STATE SURCHARGE = $56.00 each TANK, (see CA HEALTH d SAFETY CODE Sec 25207 for ability) <br /> I <br /> T I Tanks x $56.00 1906 1987 1908 1989 <br /> Y (enter iiKk and year) <br /> 4 <br /> EEFSURE (Removal or Closure-in-place) <br /> $90.00 each TANK 1 Tanks___ x $90.00 $ ��URE (Only allowed one time for up to two years) <br /> SURE FEE = 180.00 each TANK 1 Tanks x $80.00 $ <br /> PLPLA:NCHECK <br /> N CHECK (Installation or Repair) <br /> L <br /> A <br /> N FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> R REPAIR <br /> E TANK REPAIR FEE _ $110.00 each TANK Itobe <br /> _ x (110.00 f <br /> P <br /> A <br /> I PIPING REPAIR/CLUSURE/REMOVAL (Fees are per hour, minimum one hd on plan submittal)R <br /> UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION when applicable) INSPECTION ON <br /> FEE = $30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE f 0 <br /> OFFICE USE ONLY <br /> SNEEPS 1 COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD HECK ASH RCVD BY DATE RECEIVED PERMIT I <br /> ' <br />