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n reuulrYs)rt NAME FACILITY CONTACT NAME <br /> C HICKII (BQTHAM <br /> STREET ADDRESS SITE PHONE 1 frith Arel Code) <br /> fi �3S f�v12oT2A s r cP0r - I) '� - ( ") 1 <br /> Y CITY S"rSTATE 1IP COBE 1 of TANK'S <br /> OCKT0IJ CA p at Site 2 X 12;000 GA" TAu,CS <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> L �RtvtC AS �JU <br /> I MAILING ADDRESS <br /> c APPLICANT PHONE I (Vith Area Code) <br /> N CITY STATE 71P CODE Qnstallat <br /> LICATION <br /> r <br /> ion, etc.) <br /> FACILITY FEE = 5100.00 each SITE ADDRESS per YEAR <br /> A TOTAL <br /> T 1986 1987 1988 1989 <br /> I $ <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks 5 1150,00 1986 1987 1988 1989 <br /> A (multiply-$ by fee Ior <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T t Tanks a $56.00 1986 1987 1988 )989 <br /> Y (enter amount and year) <br /> i <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = 590.00 each TANK1 Tanks <br /> S s 190.00 <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TAM 1 Tanks : $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> H PLAN CHECK FEE _ $30,00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> P. <br /> E TANK REPAIR FEE = $110.00 each TANK 1 Tanks s $110.00 f <br /> P <br /> A <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 = 1130.00/hr FEE a 135.00/hr FEE _ $35.00/hr f <br /> TOTAL DUE $ ( ,,��; <br /> OFFICE USE ON(Y <br /> Ej <br /> COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVO CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br />