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juAtguloi L..JI+AL HLAL'l M UlS I k1G l !GROUND STORAGE TANK PROGRAM - FEE . WORKSHEE RFFACILITY/S TE NAMEFACILITY CONTACT NAME . 0 - I M J_ SITE PHONE # WITH AREA oDE L STREET ADDRESS T S Y CITY ATE IIP CODE 96at Site I of Tanks � C A a 33� {/ F APPLICANT/BILLING NAME APPLICANT CONTACT NAME / ,(/ L I MAILING ADDRESS � t APPLICANT PHONE WITH AREA CODE _ �t� /I9 �- j,�y') g2� CITY _- ATE ZIP CODE TYPE of APPLICATION M(/�n7J / � �/7� / CLOSURE,-INSTALLATION ETCH /D5U� * _T........_......._......_.-..S_..F.--•-_/.V__._..__..__..__"_-----.___.__..._..._..._.._--__.---_-.-.-• -�`//ll.. _.••GGLS"1/G�_ FACILITY FEE = $100.00 each SITE ADDRESS per YEARTOTAL A_..........._._..--_._..._....................._........._..- _-- __ ___.... _..............................._.__._.._......_..............................._......_.................._...-_-...._...._..__..._..__...._.._.._.... _..__..._..._ ._.......__....__... C 1986 1987 1988 1989 ............. E TANK. FEE = $50.00 each TANK _..................._......._......................_........................_...__..._._....._..._.............._..... _....._._..... F I Tanksx $50.00 1986 1987 1988 1989 A (mu 1 t i p Ty_B_by fee for ....___...__.._._____..._.�____...._.._.___...__._.._._.___._._.._.___._.___._..__._....__......_�._.._.._..__._._.___._____...._____.._.___...._....... C each year applicable) I L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH !t SAFETY CODE Sec 25287 for applicability) T...1 Tanks __...__.x $56.00_..-_._--•--.__.__ .--...._1986 1987__.._ 1988 ..�� -. 1989 ----- Y (enter amount and year) — -----_.......... _...._..._._.._._._..._.._.----......_.__.....______.__.._._...._..._.._ f ......... C PERMANENT CLOSURE (Removal or Closure-in-place) 0 CLOSURE FEE = $90.00 each TANK # Tanks x $90.00 $ - ---- U......... R TEMPORARY CLOSURE (Only allowed one time for up to two years) TEMPORARY CLOSURE FEE = $80.00 each TANK I I Tanl;s x $90.00 $ ..................... . P PLAN CHECK (Installation or Repair) A $ N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION ..............._...................I........._..._..............____...__..__._._.._.......__ __._.._._..........._...—...............-......... _ REPAIR R TANK, REPAIR FEE = $110.00 each TANK I I Tanks x $110.00 $ E _...................._............................ _......_......_...._.._--..... --._.............._......_..........._..__._.._...._..... A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION (when applicable) (when applicable) (when applicable) FEE _ $30.00/hr� FEE - $3,,.00/hr� FEE _ $35.00/hr� $ __.__._.__...__...._.._._....................__._..._._. __.._.......... _�. _.._....._..__.__... _ TOTAL DUE ;_..__... � ._.— OFFICE USE ONLY i lllll!!!I!III�II�!!IIIh�II�IIIIAII llllln�!II�II!!IIII!�IlIII�III�IIn lllll�!I�I�Illll�fll!nll IIIIIIIIIIIIan!!UIIIIIIII9!I IIIII�!!�!I!r!I!!!�I!!!I!Iln!!II�!II!Ilii!�911IIIIIIIIII��IIIIIIII!IIIIIVIIuII III!!iIIIIIII�IIIIIIIIIuIIIiIIIIII!I�II�I�IIII IIIIIIIIIIIIIIIIIIIIIIII�Illlllll lllll�l�lnllll��llll�!IIII!III�!!IIIIIIIIIIIII II�II�IlIIIIIIIIIIIIIIIIIIIIIII!IIIIIIIIIIIIIIIIII! SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT P.CVD CHECK #/CASH RCVD BY DATE RECEIVED PERMIT I .. _........._...__...._.__.._...._._......._..._._.._.__...._....._. _.. _..... . _._._...__..............._...................... ...._.._ ..............._........._..._...._................__............ ��Iilllfil�llln!nlllllh!IIlIIIIII!I�III,i ,!I�!�III��IIII�I!IIIII�II IIIII�AIIII��I91nll��llll,Il�llllflll IIIIII!iil��ll�Il�lll lnlll illlllll��III�InII1�AIInIIII��IIII�P11)91' •