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1,0/20/2000 11:35 20946831& FIFTH FLOOR PAGE 04 <br /><�` • �-- x i i r-UbLK, mtzALrH SERVICES-ENVIRQNM <br />UNDERGR ND STORAGE <br />AL HEALTH DIVISION <br />TANK PROGRAM <br />FEE WORKSHEET <br />FACILITY NAME <br />FACILrTY CONTACT NAME <br />MA2Ke i- 4 1399' <br />M1K� /44%2.Vc[Ui <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />1 t 53 L 1r1cULN <br />e35 - 9 Z&•5� - <br />CITY <br />STATE ZIP CODE <br />of rANKs aT sITe <br />T>z,4GEY <br />CA 153.71 <br />APPLICANT BtLUNG.NAME <br />APPJ !CANT CONTACT NAME <br />12t/?n(Crtc` CTtVr2oNHE�vTAi- <br />, jtJe . <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE 0 WrrFi AREA CODE <br />252-s- W. ,8cl"a,jg- 31_JA• <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />BU/L>gR1�iK- <br />- <br />Closure Installation Remirr _etrofit <br />ACTIVE FACILITY <br />$500 PEE INCLUDES !=AGILITY FEE + 1 TANK <br />{5170) X tanks1985' 1999 <br />(# ) X (# of applicable) <br />2000 <br />_ . <br />$125 PER TANK AFTER FIRST TANK <br />years <br />$ N <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $8/ TANK <br />S <br />STATE SURCHARGE FOR FACJUTIES NOT ALREADY ON INVtNTORY IN A CUPA PROGRAM = $10 / FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place) <br />TANK 10 # s <br />TEMPORARY CLOSURE <br />CLOSURE FEE= $2$1 /TANK <br />I # TANKS X 5261 = <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $261 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Ins actions <br />TANK tD # (s) : <br />j <br />PLAN CHECK FEE = S696! FACILITY I <br />