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BOARD OF TF �^ry uHwu ry Lullm c <br /> .lames Cutber' . ERGROUND STORAGE TANK PROGRAM FEE AORKSHE <br /> Mary ia"L <br /> Palricla"' <br /> 'LIIY/SITE NAME FACILITY CONTACT NAME <br /> T- <br /> C <br /> � . o I VVEs� �✓ r�1ErE�sEnv�c� <br /> 1 STREET ADDRESS SITE PHONE # (with Area Code) <br /> 1 ST tia <br /> - z <br /> T <br /> 33 <br /> Y CITY STATE 21P CODE TANK'S �� C�0 -D1 LA— <br /> ite <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P S5ieV16 /{,L SSS c <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # (with Area Code) <br /> C2 - -- -6J 24 <br /> A <br /> T CITY STTATE ZIP CODE TYPE of APPLICATION C 'Losuae <br /> S 0 (Closure, Installation, etc.) <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 OGG 1989 <br /> T f <br /> I <br /> E TANK FEE = $50.00 each TANK <br /> F # Tanksx $50.00 1986 1987 1988 1989 <br /> A (multiply#_by fee for $ <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH f SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T # Tanks x (56.00 1386 1987 1988 1983 <br /> Y (enter ii65it and year) f <br /> C PERMANENT CLOSUR(- Remova or Closure-in-place) <br /> L <br /> O CLOSURE FEE = $90.0 each TANK f Tanks-j(- x $90.00 f <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tiae for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK # 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 # Tanks x $110.00 $ <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R 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 Is 7 <br /> OFFICE USE ONLY <br /> SWEEPS # COMP # LOC CODE DIST CODE I AMOUNT DUE AMOUNT RCVD CHECK #/CASH RCVO BY DATE RECEIVED PERMIT # <br /> mama=== <br />