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1 <br /> JNDERGROUND STORAGE TANK PROGRAM - FEE WOR6ft T <br /> FAPPLICANT/BILLING� <br /> SITE NAME FACILITY CONTACT NAME <br /> ` C S M'�DRESS llJ�w10 %' S[1E PHONE tl (vith Area Code:( �1 ( S+ `i 797 STATE ZIP CODE 1 of TANK'S <br /> M Z at Site <br /> /BILLING NAMEAPPLICANT CONTACT NAME <br /> 1/�l l� S C—tjDDRESS APPLICANT PHONE 1 (with Area Code) <br /> N CITY STATE ZIP CODE TYPE of APP <br /> T U2LlJC1(—� osure, nstallation etc. W <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR , ' TOTAL <br /> A <br /> T 1986 1987 MM , l��?��89 <br /> I -- <br /> I]F E TANK FEE = $50.00 each TANK <br /> F f Tanks _ _ x $50.00 1986 1987 1988 I 1939 <br /> A (oultipl'y i by fee for <br /> C each year applicable) $ <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK. (see CA HEALTH t SAFETY CODE Sec 25281 for applicability) <br /> I <br /> T 1 Tanks x $56.00 1986 1987 1588 1939 <br /> Y (enter amount and year) <br /> i <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK <br /> S f Tanksx 130.00 $ <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tine for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK f Tanks x $80.00 $ <br /> ---- <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 1 Tanks x (110,00 ; <br /> -- <br /> A --- <br /> I PIPING REPAIR/CLOSURE/REMOVAL (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 f <br /> TOTAL DUE f (�� vv <br /> OFFICE USE ONLY <br /> SWEEPS i COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVO BY DATE RECEIVED PERMIT 1 <br /> C►M!:..7+. to .:�.i, -YP :f� ,r. <br /> i.�f�y. a'};:ti•e.y.�wv lr.Y:/as. .7« :walti <br /> - <br />