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'DERGROUND STORAGE TANK PROGRAM - FEE UNKSHF <br /> F FACILITY/SITE NAME FACILIiu CONTACT NAME <br /> oRA/Ja /N✓EsT)nf�TsdlMeY 70- 4ia9- ,P690 <br /> L STREET ADDRESS SITE PHONE 1 (with Area Code) <br /> DiJ D'GALA L�bbrid �.1 <br /> T <br /> Y CITY STATE ZIP CODE 1 of TANK'S <br /> (:F OnI (19 �%�• e/� at Site <br /> A APPLICANT/BILLING NAME APP CANT CONTACT 7L"'j <br /> P CL 0DQA00 /�/✓EST1"eA)rS �filY/Gv <br /> I MAILI ADDRE APPLICANT PHONE 1 (with Area Code) <br /> C • C) . �c /S 7 <br /> NCITY S ATE Z P CODE . TYPE of APPLICATION n' _ <br /> T OOLXS7-o CR . A V5353 (Closure, Installation, etc.)(-40j-v - <br /> A FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> T 1986 1987 1988 1989 <br /> I f <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanksx $50.00 1986 1987 1988 1989 <br /> A (multipTy_1_by fee for <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 x $56.00 1986 1987 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 x $90.00 f / g"p O O <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 $80.00 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 /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK 1 Tanks z $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 EVALUATI=CONSTRUCTION SAMPLING <br /> (when applicable) N INSPECTION <br /> FEE = $30.00/hr FEE _ $35.00/hr FEE = $35.00/hr $ <br /> TOTAL DUE Is / p , O o <br /> OFFICE USE ONLY <br /> SWEEPS t COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br />