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�r..`�+ ... "AL. HV-ALI-H Di l'RIC1" <br /> FACILITY/SITE NAME <br /> ERGROUND STORAGE TANK PROGRAM - FEE WKSH <br /> A <br /> om- Ca FACILITY CONTACT NAME <br /> C <br /> I !Z ;GI r`Y aF Sri 4�- �5t' <br /> L STREET ADDRESS <br /> Y qc /v SITE PHONE I <br /> WITH AA[A coo[ <br /> Y c1rY <br /> STAT IIP CODE I of ranks <br /> A APPLICANT/BILLING NAME at Site <br /> P <br /> P APPLICANT CONTACT NAME <br /> L <br /> I RAILING ADDRESS <br /> C <br /> A APPLICANT PHONE I y,Ta AALA carrc <br /> N CITY <br /> 1 STAT IIP CODE TYPE of APPLICATION <br /> CLOg4AE� 1M41TALLA IlaH, arC. <br /> A FACILITY FEE = 5100.00 each SITE ADDRESS per YEAR <br /> TOTAL <br /> 1996 1987 1988 1989 <br /> V <br /> E TANK FEE 150.00 each TANK <br /> F I Tanks Z- z 150.00 1986 <br /> A (sultipfy-1_by fee for 1987 1989 <br /> C each year applicable) <br /> l <br /> L STATE SURCHARGE = 156.00 each TANK (see <br /> 1 CA HEALTH 6 SAFETY COOS Sec 25281 for applicability) 1 �o <br /> T 1 Tanks 'v z $56.00 <br /> Y (enter iiount and year) 1986 1987 1900 1909 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) t <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK <br /> � 1 Tanks _ z 190.00 M <br /> R TEMPORARY CLOSURE <br /> E (Only alloyed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $00,00 each TANK <br /> Ta)ks_ _ _ x $80,00 � <br /> P PLAN CHECK <br /> L (Installation or Repair) <br /> A <br /> N PLAN CHECK FEE = 130,00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> 1 <br /> R TANK REPAIR FEE : $110.00 each TANK <br /> E I Tanks z 1110.00 <br /> P 1 <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour minimum one hour to be-paid on lan submittal) <br /> R UNAUTHOR17EO RELEASE EVALUATION CONSTRUCTION INSPECTION <br /> (when applicable) fp �iltal) <br /> SAMPLING INSPECTION <br /> applicable} (wheapplicable) <br /> FEE = 130.40/hr <br /> FEE = 135,OO/hr <br /> FEE _$35.00/hr 1 <br /> OFFICE USf osLy TOTAL DUE s <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNTRCVD I I I I I � . <br /> r I <br /> CHECK U CASH RCVD BY DATE RECEIVED PERMIT I <br />