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GROUND STORAGE TANK PROGRAM FEE NORKSHEE <br /> FACILITY CONW NAME <br /> F FACILITY/SITE NAME <br /> 1C L- <br /> � ) yYEs��,✓ /�'I E-rE�SerzvlcE <br /> 1 SITE PHONE # (with Area Code) <br /> L STREET ADDRESS ST 9-1) _ z <br /> T STATE ZIP CODE i of TANK'S ��� /r l <br /> Y CITY CA at Site l <br /> �0 1 <br /> APPLICANT CONTACT NAME <br /> A APPLICANT/BILLING NAME <br /> P 1 �(Z) I �T S��ZVIGG ll,L mss c <br /> L APPLICANT PHONE # (with Area Code) <br /> I MAILING ADDRESS <br /> C 2 -- J7� <br /> A STATE ZIP CODEt- TYPE of APPLICATION C l-QSUR <br /> N CITY `J CA sure, Installation, etc.) <br /> T <br /> TOTAL <br /> fACILITY FEE _ $100,00 each SITE ADDRESS per YEAR <br /> A 1986 1987 1988 1989 <br /> C <br /> T $ <br /> 1 <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F i Tanks _ _ x $50.00 1986 19E 1988 198'3 <br /> A (tultipTy i by fee for f <br /> i C each year applicable) <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T #Tanks_____ x$56.00 1986 1987 1988 1989 <br /> Y (enter mount and year) $ <br /> C PERMANENT CLOSUR Remova or Closure-in-place) <br /> L # Tanks_ [_ x $90.00 $ <br /> O CLOSURE FEE_ $90,0 each TANK <br /> S <br /> U - <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E TEMPORARY CLOSURE FEE = $80.00 each TANK # Tanks_____ z $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 /> Rt Tanks_____ z $110.00 $ <br /> E TANK REPAIR FEE = 5110.00 each TANK <br /> P <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R SAMPLING <br /> UNAUTHORIZED RELEASE EVALUATION INSPECTION INSPECTION <br /> (when applicable) <br /> FEF7$35,$35.00/hr FEE _ $35.00/hr $ <br /> FEE= 530.00/hr � <br /> TOTAL DUE <br /> OFFICE BSE ONLY <br /> SNEEPS # COMP i LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK #/CASH RCVD BY DATE RECEIVED PERMIT # <br />