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Q"1% .J ' 9uulw LUL;AL HLALT:i DI5'"1CT 4 <br /> ,.,4ROUND STORAGE TANK PROGRAM - FEE WORKSHEEr.Ror A SIL <br /> A FACILITY/SITE NAME FACILITY CONTACT NAME <br /> �� li� �p2 ��Cx� IOnS <br /> L STREET ADDRESS SITE PHONE 1 WITH AREA c==[ <br /> T <br /> Y CITY STAT IIP CODE 1t 0l iTanks <br /> fi �e r <br /> CG aSte <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P PAYMENT <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA coot <br /> C <br /> AMAY t 1 910 <br /> N CITY STAT 21P CODE TYPE of APPLICATION <br /> T CL=tluA C. »AtAIIAIIOH. [Tc. <br /> A FACILITY FEE _ $I(-4Nj WfiY RESS per YEAR TOTAL <br /> C 1986 1981 1988 1989 <br /> T _ <br /> I S <br /> V <br /> E TANK FEE = $50.00 each TANK ���'� _ c-: <br /> F 1 Tanks x 450.00 1986 1987 1988 1989 �/ G <br /> A (aultipry 1-by fee for <br /> C each year applicable) C SC S C S S D t <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for applicability) <br /> 1 <br /> T 1 Tanksx $56.00 1986 1907 1988 1989 <br /> Y (enter mount and year) _ ) <br /> C PERMANENT CLOSURE (Resoval or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks <br /> S <br /> U - <br /> R TEMPORARY CLOSURE (Only allowed one tine for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $00.00 each TANK 1 Tanks x fB0.00 4 <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION t <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK 1 Tanks x 1110.00 S <br /> E <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimus one hour to be paid on plan subaittal) <br /> 1 <br /> R UNAUTHORIlED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 130.00/hr FEE _ $35.00lhr FEE _ $35.00/hr t <br /> TOTAL DUE $ J C <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK /CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> 7 U9 �' �� m °11 111102113181NNI11P111�g(�' � ' <br />