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.+nn .zun,:ulr L�z:nL FicnLlH Ut5lr<ac: ! <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE NORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> L STREET ADDRESS SITE PHONE / (with Area Code) <br /> I <br /> T <br /> Y CITY <br /> T C� � Sj�T IIP C s t of TANK'S 2 <br /> J (,, .S at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P ,G a ,U �BYL <br /> P <br /> L <br /> C MAILIN ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> A '2 269 4632 <br /> TSTAT <br /> CITY n E II CODE - TYPE of APPLICATION <br /> J L/ 5.205 (Closure, Installation, etc.)�7/j;2 z <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> 1 $ <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks z $50.00 1986 1987 1980 1989 <br /> A (multipTy i-by fee for <br /> C <br /> each year applicable) f <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH d SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter iiouot and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 6 CLOSURE FEE = $90.00 each TANK 1 Tanks-2,- x $90.00 f 0 .00 <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 z $00.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f <br /> R REPAIR <br /> E TANK REPAIR FEE _ $110.00 each TANK <br /> P t Tanks z $110.00 f <br /> A <br /> 1 PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> 7-[FtE _ $30.00/hr FEE = $35.00/hr FEE _ $35.00/hr f �_ <br /> TOTAL DUE is <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE I AMOUNT RCVD I CHECK 1/CASH RCVD BY I DATE RECEIVED PERMIT 1 <br />