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U' ROUND 6TO2AGE TANI; PRU6RAM FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONT AME <br /> c o W ESi cin/ h1 ETg7jz E2vlc6 <br /> SITE PHONE t (with Area Code) <br /> L STREET ADDRESS _ <br /> I 33 57 2 0 <br /> T STATE IIP CODE # of TANK'S <br />• _:, <br /> Y CITY ' Cfd at Site <br /> is �d -DI <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P J (z1.4 ET &57eV IGG c <br /> P <br /> L APPLICANT PNDNE # (with Area Code) <br /> I MAILING ADDRESS <br /> A STATE ZIP CODE TYPE of APPLICATION C �OStJGZc <br /> N CITY C� (Closure, Installation, etc.) <br /> I S OG f <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br /> TOTAL <br /> A 1986 1987 1988 1989 <br /> C <br /> T $ <br /> E TAW FEE _ $50.00 each TANK <br /> F # Tanks 1 $50.00 1986 1981 1988 1989 Y <br /> A (multiply i by tee for f <br /> C `eac:W year applicable) <br /> I <br /> L STATESURCHARGE = $56.00 each TANK (see CA HEALTH k-SAFETY CODE Sec 25287 for applicability) <br /> . <br /> T # Tanks x $56.00 1986 <br /> I 1987 Be191989 <br /> Y (enteramount and year) S <br /> a. <br /> C PERMANENT CLOSUR Remova or Closure-in-place) <br /> o CLOSURE FEE = 590.0 each TANK 1 Tanks_,_ x $90.00 $ <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> s } <br /> E <br /> # Tanks_____ x $80.00 $ <br /> TEIIPORARY'CLOSURE FEE = $80.00 each TANK <br /> P PLAN-CHECK-(Installation-or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = S30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> R # Tanks x $110.00 S <br /> E TANK REPAIR FEE _ $110.00 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 t111AUTHORIZED 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 f QU <br /> ,WICE'USE ONLY <br /> SyEEPS';{ COMP ; LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK t/CASH RCVD BY DATE RECEIVED PERMIT # <br />