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E PACILITYISITE NAME <br />,'. A <br />C° <br />I <br />STREET ADDRESS <br />T <br />Y CITY <br />A APPLICANT/BILLING NAME <br />P <br />P <br />L <br />I MAILING ADDRESS <br />C <br />A <br />N CITY <br />DIST <br />�QOROUIND STORAGE TAW PROGRAM - FEE VORKSHEEIM� <br />FACILITY CONTACT NAME <br />I <br />(G%7 0r <br />SITE PHONE 1 YET" AREA cooc <br />STAT IIP CODE 1 of Tanks <br />at Site <br />APPLICANT CONTACT NAME <br />APPLICANT PHONE 1 Mtr" ARCA eoec <br />STAT ZIP CODE TYPE of <br />CL0r4AE 1m4TALLATio ETC. <br />FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR <br />C 1986 1987 1988 1989 <br />I <br />V 1 <br />E TANK FEE = $50.00 each TANK <br />F i Tanks x $50.00 1986 1987 1988 <br />A (wultipfy I"by fee for <br />C each year applicable) 1 <br />t 60 <br />L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH is SAFETY CODE Sec 25287 for applicability) <br />t <br />T 1 Tanks.....x 156.00 1986 1987 1988 1909 <br />Y (enter t and year) <br />C <br />PERMANENT CLOSURE (Resoval or Closure -in-place) <br />L <br />0 <br />CLOSURE FEE = $10.00 each TANK <br />1 Tanks <br />_ x (90.00 <br />U <br />R <br />E <br />TEMPORARY CLOSURE (Only allowed one tine for up to two years) <br />TEMPORARY CLOSURE FEE = $80.00 each TANK <br />t Tanks <br />x $80.00 <br />PLAN CH (Installation r Repair) <br />L <br />A <br />N PLAN CHECK FEE -- 130.00 each SUBMISSION/RESUBMISSION <br />REPAIR <br />R TANK REPAIR FEE = $110.00 each TANK <br />1 Tanks <br />_ x $110.00 <br />P <br />RA PIPING REPAIR/CLOSURE/REMOVAL (Fees are per flour, ®inicus one <br />hour to be <br />paid on plan subcittal) <br />UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION <br />(when applicable) <br />SAMPLING INSPECTION <br />(when applicable) <br />(when <br />applicable) <br />FEE = 130.00/hr <br />FEE _ $35.00/hr <br />FEE = <br />135.00/hr <br />OFFICE USE ONLY <br />TOTAL DUE <br />TOTAL <br />SWEEPS 1 COMP i LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD NEG /CASH KCVO DY DATE RECEIVED PERMIT 1 <br />3n/ o ar. 35.� '3AO ('7. * /® &D 7 Y <br />