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urtimv uAmamu 1 my Lu t, HL HCriL I rr U a <br />GRGROUND STORAGE TANK PROGRAM - FEE WORKSHEW J GamJ'S i):21 <br />F <br />FACILITY/SITE NAME <br />FACILITY CONTACT NAME <br /># Tanks---_q_x $90.00 <br />$ °= <br />S <br />L <br />STREET ADDRESS /I <br />SITE PHONE # (with Area Code) <br />I <br />l/ -j : kv V <br />1987 <br />T <br />1989 <br />T <br />Y <br />CITY <br />—� <br />STATE <br />ZIP CODE <br /># of TANK'S <br />at Site <br />A <br />APPLICANT/BILLING NAMO <br />APPLICANT CONTACT NAME <br />P <br />$ <br />I <br />MAILING ADDRESS;- 7 <br />APP CANT PHONE # (with Area Code) <br />A <br />U . - �/ i I'�v i°iE (9 /� <br />� <br />V <br />E TANK FEE _ $50.00 each TANK <br />F # Tanks x $50.00 <br />A (multiply -f -by fee for <br />1986 <br />1987 <br />N <br />CITY- <br />ST TE <br />ZIP CODE <br />TYPE of APPLICATION— <br />T <br />� <br />�� <br />(Closur ,, Installation_' etc.) <br />FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br />TOTAL <br />A <br /># Tanks---_q_x $90.00 <br />$ °= <br />S <br />N <br />U <br />R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br />$ --jijq" <br />C <br />1986 <br />1987 <br />1988 <br />1989 <br />T <br />I <br />$ <br />V <br />E TANK FEE _ $50.00 each TANK <br />F # Tanks x $50.00 <br />A (multiply -f -by fee for <br />1986 <br />1987 <br />1988 <br />1989 <br />C each year applicable) <br />$ <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 $56.00 <br />Y (enter 5655t and year) <br />1986 <br />1987 <br />1988 <br />1989 <br />$ <br />C PERMANENT CLOSURE (Removal or Closure -in-place) <br />PLAN CHECK (Installation or Repair) <br />L <br />0 CLOSURE FEE _ $90.00 each TANK <br /># Tanks---_q_x $90.00 <br />$ °= <br />S <br />N <br />U <br />R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br />$ --jijq" <br />E <br />TEMPORARY CLOSURE FEE _ $80.00 each TANK <br /># Tanks x $80.00 <br />$ <br />P <br />L <br />PLAN CHECK (Installation or Repair) <br />A <br />N <br />PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br />$ --jijq" <br />R REPAIR <br />E TANK REPAIR FEE _ $110.00 each TANK # Tanks x $110.00 $ <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 <br />UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br />(when applicable) INSPECTION INSPECTION <br />FEE _ $30.00/hrl IFEE _ $35.00/hrl IFEE _ $35.00/hrl Is <br />TOTAL DUE 1$ <br />OFFICE USE ONLY <br />