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UNDER6RGJND STORAGE TANK FROSP.AM - FEE LORK,SHEFT <br /> `raWL1Tl-/SITE NAME <br /> l SI/ FACILITY Ws,.A T NAMEW)tb 4;41 <br /> — ---- <br /> VL STREET ADDRESS <br /> �- SITE PHONE t WITH AREA CODE <br /> TCa <br /> Y CITY <br /> rR STAT IIP CODE 1 of Tanks <br /> q5,3l at Site W n <br /> A APPLICANT/BIL 6 NAME -- <br /> P <br /> PI <br /> .11 !! ,, APPLICANT CONTACT NAME <br /> WL L_.(.. 1�. I <br /> IMAILING ADDRESS — g — � 4 FI K, <br /> C p APPLICANT PHONE t <br /> WITH AREA CODE <br /> A CITY JS/� _ 4$ <br /> T Cr A I — JAT ZIP CODE TYPE of APPLICATION <br /> (,q CLOSURE. INETALLATIDN. ETC. �• r <br /> FACILITY FEE = $100.00 each STTE ADDRESS per YEAR <br /> T -- _ f TOTAL_ <br /> 1986 1987 1988 1989 <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks x 150.00 1986 1987 1988 1989 <br /> A (mach yea Iapp fee for ®t7 <br /> C each year applicable) F/ �� ✓ <br /> I $ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks A x 156.00 1986 1987 1988 <br /> Y (enter iiiiuit and year) 1983 <br /> i <br /> C PEP.MANENT CLOSUD.E (Removal or Closure-in-place) <br /> 0 CLOSURE FEE = 190.00 each TANK 1 Tanks__.?-, x $90.00 f <br /> S <br /> 0 � <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANY, t Tanks x $80.00 <br /> P PLAN CHECK (Installation or Repair) <br /> L- P Elv gD <br /> A - <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f <br /> cis <br /> REPAIR <br /> RONMENT <br /> E A <br /> R TANK REPAIR FEE _ $110.00 each TANK 1 Tanks P 00 <br /> --- f------ <br /> F _ <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 SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 130.00/hr FEE = $35.00/hr FEE _ $35.00/hr $ <br /> q� • Db <br /> OFFICE USE ONLY TOTAL DUE I <br /> SLEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT P.CVD CHECK 1/CASH RCVS BY DATE RECEIVED PERMIT 1 <br /> (w�o3 C)q 101 S l� Y <br /> to—s <br /> MIT Tse ' <br />