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114IL�11 YVI\11141 1\IIIIL <br /> E,t-QOR?QO /N✓EsT ��,�rs BA �0 a - a69v <br /> STREET ADDRESS U�y x` / SITE PHS 1 (with Area Code) <br /> I At / pl-42A <br /> T &NW <br /> Y CITY ((�� /� STATE ZIP CODE 1 of TANK'S <br /> U7DCTOrj LY4L at Site <br /> A APPLICANT/BILLING'NAME APP CANT CONTACT NAM <br /> P (5L ®OQA 90 /N✓EST/YI�nITS �fiI19Go <br /> I MAIL[ ADDRE APPLICANT PHONE 1 (with Area Code) <br /> n D . — <br /> N CITY /y SLATE I P CODE TYPE of APPLICATION n, — <br /> T OO�ST�J ( A , C'A5353 (Closure, Installation, etcJ( (��/ <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1968 1989 <br /> T <br /> I f <br /> T- <br /> V- <br /> E <br /> TANK FEE = 150.00 each TANK <br /> F 1 Tanks a $50.00 1986 1987 1988 1989 <br /> A (multiply-1-hy lee for <br /> C each year applicable) f <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T t Tanks x 156.00 1986 1981 1988 1989 <br /> Y (enter iiount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks 2 x $90.00 f 00 <br /> S <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 x 480.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR <br /> P, <br /> E TANK REPAIR FEE _ $110.00 each TANK 1 Tanks x $110.00 1 <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 = $30.00/hr FEE _ $35.00/hr FEE = $35.00/hr $ <br /> TOTAL DUE Is 0 , D C,> <br /> OFFICE USE ONLY <br /> SWEEPS 1COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> 43 ��D•�'x' l(�•a) /v?3 /✓C � 1 <br />