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r �r "" r+c- NLLiLIN 1.)1SINIC1 <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FA <br /> FACILITY CONTACT NAME <br /> r- nlFSITE PHONE 1 WITH •WC. Coo■ <br /> STAT ZIP CODE 1 of Tanks <br /> A APPLICANT/BILLING NAME at Site <br /> P APPLICANT CONTACT NAME <br /> P <br /> L <br /> 1 MAILING ADDRESS <br /> C APPLICANT PHONE I WITH .+C. Cool <br /> A <br /> H CITY <br /> T STAT ZIP CODE TYPE of APPLICATION <br /> CLOtlw.L. IWLT.LLw,IOW. LTC, <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br /> C150E TOTAL <br /> 1907 1908 1909 <br /> V <br /> E TANK FEE = {50.00 each TANK $ <br /> F 1 Tanks _ _ r {50.00 t9O6 <br /> A (multlpEy 6y lee for 1981 1988 1989 <br /> C each year applicable) <br /> 1 <br /> L STATE SURCHARGE <br /> 1 = f5L.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 15287 for applicability) $ <br /> T 1 Tanks _ a $5L.00 1986 <br /> Y (enter iiount and year) 1987 1908 19(19 <br /> L <br /> 1 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90,00 each TAH <br /> 1 Tanks _ __ $90.00 t <br /> R TEMPORARY CLOSURE (Only allowed <br /> E one time lar up to two years) <br /> iCMPORARY CLOSURE FEE _ $(10.00 each TANK <br /> 1 Tanks _ ___ r f00.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> f <br /> REPAIR <br /> R TANK REPAIR FEE = 1110.00 each TANK <br /> E 1 Tanks L t110.00 <br /> A PIPING REPAIR/CLOSURE/REMOVAL (fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION <br /> (when applicable) (When applicable) .,AMPLING INSPECTION <br /> (uhen applicable) <br /> FEE _ {30.00/hr FEE _ $35.00/hr <br /> FEE _ {3,.00/hr $ <br /> OFFICE USr ony TOTAL DUE <br /> I I <br /> SWEEPS COMP I LOC CODE <br /> DIST <br /> CODE AMOUNT DUE AMOUNT RCVD CHICK I/CASH KCVO BY GATE RECEIVED PERMIT <br /> III ?"P�"i�tlI 1 fl KC1 <br /> RAI, <br /> III <br /> 11111 ' fit m NIItR' Iml " � 'tl�IVAkllvylpl 6911);DII'I!I'Tlp'1PIII)11"' <br />