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UNDERGROUND STORAGE TANK PROGRAM - FEC WORKSHEET <br /> F FACILITY/SITE NAME FAC TY CO r"T NAME <br /> MIC s G <br /> 1 � 5 STREET ADDRESS SITE PHONE 1 (with Area Code) <br /> T Yn , rJ S- <br /> Y CITY ATE ZIP CODE I of TANK'S <br /> I] <br /> at Site <br /> A APPLICANT/BILLING NME APP CANT CONTACT NAME <br /> P <br /> L k�" I L171 <br /> MAILING ADDRESS APPLICANT PHONE 11 (with Area Code) <br /> A W , `G lel `7 - - C I 5 3 <br /> N CITY STATE 1 P CODE TYPE of APPLICATION <br /> T �. - j (Closure, Installation, etc.) <br /> A FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1969 <br /> T <br /> I # <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks x $50.00 1986 1987 1988 1989 <br /> A (Aultipf'y-`-by fee for <br /> C each year applicable) # <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH Z SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T I Tanks x 156.00 1986 1987 1988 1989 <br /> Y (enter ii6ik and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK I Tanks-QZ-- x #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 <br /> E TANK REPAIR FEE _ $110.00 each TANK <br /> P I Tanks x $110.00 # <br /> A <br /> I PIPING REPAIR/CLOSUREIREMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = $30.00/hr FEE = #35.00/hr FEE _ $35.00/hr # <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT I <br /> 7 - y 32 ) lo9a°0 1X4'13 5-119i <br />