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•_nDERGROUND STORAGE TANK PROGRAM - FEE YORK, <br /> }i F 'ACILITY/SITE NAME <br /> A <br /> _ FACILITY CONTACT NAME <br /> I L <br /> L STREET ADDRESS <br /> T SITE PHONE 1 (with Area Code; <br /> Y CITY <br /> 7-0STATE ZIP CODE I of TANK'S <br /> Ce at Site <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> P <br /> L <br /> 1 MAILING ADDRESS <br /> C APPLICANT PHONE 1 (with Area Code) <br /> A <br /> N CITY <br /> I STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br /> A TOTAL <br /> C <br /> T 1986 1587 1988 1989 <br /> 1 <br /> E TANK FEE = $50.00 each TANK <br /> F t Tanks o2 x $50.00 1986 1987 1988 <br /> A (�ultiply f-by fee for 1939 <br /> C each year applicable) <br /> 1 /o CJ /0 c-,;, i0o <br /> L STATE SURCHARGE _ $56.00 each TANK. (see CA HEALTH I SAFETY CODE Sec 2 ^ <br /> I <br /> 5.87 for applicability) <br /> T t Tanks o2- x (56.00 1986 l`i81 <br /> Y (enter isount and year) 1'i88 I'389 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK <br /> S 1 Tanks_: (30.00 s <br /> R. TEMPORARY CLOSURE (Only allowed one tiie for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK <br /> t Tanks x 590.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A _ <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> S <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK <br /> P 1 Tanks x $110.00 $ <br /> A <br /> 1 PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, <br /> R minimum one hour to be paid on plan submittal) <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION <br /> (when applicable) INSPECTION SAMPLING <br /> INSPECTION <br /> FEE _ $30.00/hr FEE = $35.00/hr ,� <br /> FEE = 00/hr $ <br /> /t7'j� <br /> OFIFCE USE ONLY TOTAL DUE $ <br /> a <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 7I/CASH RCVvD®B/Y DATE/RECEIVED PERMIT <br /> Vr fray f•^...�K y:� a:% . <br />