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Anil <br /> F FACILITY/SITE NAME FACILITY CON CT NAME <br /> I' LSTRE T ADDRESS SITE PHONE 1 WITH ARIA COD. <br /> 1 lrav . , . <br /> T <br /> r nn, �D <br /> Y CITY F ITATE IP CODE 1 of Tanks <br /> p G/� 'Yti CT at Site <br /> A APPLICANTIBILLING NAME APPLICANT CONTACT NAME <br /> 'ober f <br /> I MAILING ADDRESS APPLICANT PHONE 1 HITH AREA CODE <br /> C ym0 <br /> A. <br /> N CITY l STAT ZIP CODE TYPE of APPLICATION <br /> CL08UH.E. IN8TALLATIUH, CTC. <br /> ' tLLL//// '✓ [r <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> 1 1ppr" /Do , /003 s Soo <br /> E TANK FEE _ $50.00 each TANK <br /> �s � .zed '150 <br /> F 1 Tanks ...3 x $50.00 1986 1987 1988 1989 <br /> A (multipTy # by fee for <br /> C each year applicable) ISD 15-4 — lso — <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH a SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks-,,3_ x $56.00 1986 1987 1988 1989 <br /> Y (enter amount and year) lea <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> D CLOSURE FEE = $90.00 each TANK 1 Tanksx $90.00 $ <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks x $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK 1 Tanks x $110.00 $ <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = $30.00/h► FEE = $35.00/hr FEE = $35.001hr $ <br /> TOTAL DUE s <br /> OFFICE USE ONLY pot <br /> 111011;11, :991 MEN fin <br /> SWEEPS 1 COMP 1 LDC CODE DIST CODEZAMOUNTDUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> 1 f t o ° U ° 3s9 / 3�` <br />