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F FACILITY/SITE NAME UNDERGRUUNO STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY ^ ' NAME <br /> A GEwJE Kt �p�i(,J` -- cS���'�- t-�1t%f'�h1�_ <br /> I <br /> l STREET ADDRESS SITE PHONE t (with Area Code) <br /> rCk�enKtt Lqn,°a 5?o9 - 33 -4 - &Soo <br /> Y CITY STATE ZIP CODE f of TANK'S <br /> C'9 fl7y/ at Site <br /> A APPLICANT/BILLING NAME <br /> F APPLICANT CONTACT NAME <br /> P C-E",,06KC- <br /> I MAILING ADDRESSq), APPLICANT PHONE 1 (with Area _Cade) <br /> C i gox <br /> A � <br /> T CITY 1;0 O 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 /> T <br /> T 1986 1987 1988 1989 <br /> I <br /> V $ <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks x $50.00 1986 1987 1988 1989 <br /> A (multiply-i-by fee for <br /> C each year applicable) $ <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH f SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T t Tanks x $56.00 1986 1987 (9188 1989 <br /> Y (enter anount and or <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> D CLOSURE FEE _ S90.00 each TANK <br /> 5 t Tanks __ x $90.00 <br /> U <br /> P. TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK t 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 $ <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK <br /> P 1 Tanks x $110.00 f <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 = $30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr f <br /> TOTAL DUE Is <br /> OFFICE us[ ONLY <br /> zz, <br /> LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK t/CASH RCVD BY OATE RECEIVED PERMIT 1 <br />