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F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> j l,hn s>*p .e, Ti re u 6 her Co, <br /> L STREET ADDRESS SITE PHONE i p(with Area Code) <br /> I (✓ G d0 / J <br /> T <br /> Y CITY SCS 1 r DEO atoSiteNK'S / <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T (Closure, Installation, etc.) <br /> i <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C (986 1987 1988 1989 <br /> T <br /> I <br /> PAY <br /> E TANK FEE _ $50.00 each TANK RECEIVED <br /> F i Tanks x $50.00 1986 1987 "j=1989 <br /> A (multipTy fby fee for <br /> C each year applicable) $ <br /> I ENVAAIT TAL H <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25281 for applica Ili EALTF{ <br /> T i Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter iiouot and year) <br /> t <br /> C PERMANENT CLOSURE (Resoval or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK t Tanks___ z $90.00 t 90 <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 i Tanks z $80.00 $ <br /> P L <br /> PLAN CHECK (Installation or Repair) <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION t <br /> R REPAIR <br /> E TANK REPAIR FEE _ $110.00 each TANK i Tanks z $110.00 t <br /> p <br /> A <br /> R PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <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 f <br /> OFFICE USE ONLY <br /> E.WEEPS.1 COMP i LOC CODEDIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED PERMIT t <br /> �� <br /> 79U— <br />