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` ._. I`%L- H"ALIH 1)1 .91-R1CT <br /> �RGROUND STORAGE TANK PROGRAM - FEE WORKSHL_� <br /> A FACILITY/SITE NAME L I Z�4o <br /> C FACILITY CONTACT NAME <br /> I <br /> L STREET ADDRESS <br /> f SITE PHONE 1 NITN .Nc• coot <br /> T <br /> Y CITY <br /> STAT ZIP CODE I of Tanks <br /> A APPLICANT/BILLING NAME at Site <br /> P APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAILING ADDRESS <br /> C APPLICANT PHONE 1 NIT" A+r• coot <br /> A <br /> N CITY <br /> T STAT ZIP CODE TYPE of APPLICATION <br /> CLONwA[, INITALL„rION, ETC. <br /> A FACILITY FEE=10000 each SITE ADDRESS per YEAR <br /> 344 Re.,,c+vp,,. r4 g9 <br /> i 1986 1907TOTAL <br /> 1988 1989 <br /> 1 is <br /> V lOo /vo !b0 �K /ob C-k 400 <br /> E TANK FEE _ $50.00 each TANK <br /> f. Ics za. kg >r7..k zx.� <br /> f 1 Tanks _ _ r $50.00 1986 <br /> A (aUltipiy 1 by fee for 1987 1988 1989 <br /> C each year applicable) <br /> 1 G ac, Ian, !bo <br /> /op /bo <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) t Gov <br /> I <br /> T 1 Tanks ! : 156.00 1986 <br /> Y (enter laount and year) 1907 1900 1909 <br /> Z Z' <br /> f 2Z� <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = 190,00 each TANK <br /> S 1 Tanks Z r <br /> u <br /> R TEMPORARY CLOSURE (Only allowed o <br /> E fie tine for up to two years) <br /> TEMPORARY CLOSURE FEE = $80,00 each TANK <br /> 1 Tanks_ _ _ r $80.00 1 <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> M PLAN CHECK FEE • 130.00 each SUBMISSION/RESUBMISSION <br /> f <br /> REPAIR <br /> R TANK REPAIR FEE = 1110.00 each TANK <br /> C I Tanks __ s (110 1 <br /> P .00 <br /> A PIPING REPAIR/CLOSURE/REMOVAL (fees are per hour, minimus one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION <br /> (when applicable) (when applicable) SAMPLING INSPECTION <br /> (when applicable) <br /> FEf = 130.00/hr FEE = 135.00/hr -7O FEE _$3,,00/hr f 7D <br /> OFFICE USE ONLY TOTAL DUE f <br /> SWEEPS 1 7 �- <br /> Fy-)r( 01*0i/ <br /> COMP 1 LOC CODE DIST [ODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED I PERMIT 1 <br /> � Illm�gpbl�tlPg,7P;I�lOq�rllllrnMuunrn <br /> r DN1tlR'tlM 9B�sID1IpIPlrnentl' <br />