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..Inw uri. u11r Lux AL YfaAL I rl IJ [<..G I <br /> DERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> CKA Lj mG Jf 1 ( r <br /> 1 <br /> L STREET ADDRESS SITE PHONE t (with Area Code) <br /> Y CITY STATE ZIP CODE 1 of TANK'S <br /> KIS VA KN V E C IN ' at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> CA <br /> N CITY SJ�ITE ZIP CODE TYPE of APPLICATION <br /> 1 �j x \ L C ,1 ( (Closure, Installation, etc.) <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1906 1987 1988 1989 <br /> T <br /> 1 S <br /> V <br /> E TANK FEE = $50,00 each TANK <br /> F 1 Tanks x $50.00 1986 1987 1988 1989 <br /> A (multiply I by fee for <br /> C each year applicable) f <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25201 for applicability) <br /> I <br /> T 1 Tanks x 156.00 1986 1987 1908 1989 <br /> Y (enter 5i56it and year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK <br /> 7771t Tanks_ x $90.00 f <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks x $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE = $110.00 each TANK 1 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 = 130.00lhr FEE = $35.00/hr FEE _ $35.00/hr f <br /> TOTAL DUE Is <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP t LCODECOBE AMOUNT DUE AMOUNT RCVD (CHECK.)/CASH RCVO BY DATE RECEIVED PERMIT t <br />