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ueua96cWJN blUKAbk IAN[ PRWiIIAM • FEE VORKSHEET <br /> fACllllylSlTE NAME 1, ,ITY CONTACT NAME <br /> oz , 12E l/7r9 LS j 2r htT <br /> L STREET ADDRESS SITE PND a wl ew vv feet <br /> y CITY L oG ;TAT lip CODE 1 of Tanks , X5-06) ISOOj <br /> ! S��Fv at site �3J(aocx> <br /> F APPLICANTf11LLlNG NAVE APPLICANT CONTACT MANE <br /> P Sew\co <br /> L t.mo <br /> 1 MAILING AD ESS APPLIC T PHONE 1 wrrw Am9a 6489 <br /> A <br /> N CITY STAT 11P'fOD T I APPLICATION <br /> AFACILITY FEE ■ 1100.00 each SITE ADDRESS per TEAR TOTAL <br /> - <br /> C 1981 1987 1988 1989 !�X10 <br /> r <br /> v { <br /> E TANK FEE • 150.00 each TAM <br /> f 1 Tanks s 150,00 1981 1987 1988 1989 lotLoA (eultiplp 11y lee for <br /> C each year applicable) 1 <br /> I <br /> L STATE SURCHARGE • 151.00 lith TANK (iee CA "IN 1 SAFETY CO <br /> 1 DE Sec 15287 for applicability) <br /> I 1 tanks _uu_ots 151.00 1981 1987 1908 1389 gQ0 <br /> Y !taker ieand yew) <br /> t <br /> C PERMANENT CLOSURE (ReNral of Clowre•Ik•plact) <br /> L <br /> 0 CLOSURE FEE a 190.00 tick TAMC 1 Tants_`t:_ s 130.09 1 3 6 0 <br /> S <br /> u - <br /> R TEMPORARY CLOSURE IOoly allowed oaf life IOr up to ING years) <br /> E <br /> IEMPORARY CLOSURE FEE ■ 180.00 each TANK 1 Tanks______ s 100.00 1 <br /> P PLAN CHICK (lasiallatiot or Repair) <br /> L <br /> A <br /> H PLAN CNECK FEE • 130.00 sack SUBMISSION/RESUCMISSIOM 1 <br /> REPAIR <br /> R TANK REPAIR FEE • 1110.00 lack TANK <br /> E 1 Tantc_ s 1110.00 { <br /> P <br /> A PIPING REPAIRICLOSUREIREAGWAL (roes are per hour, 9)nisuo one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSIRUCTION INSPECTION SAMPLING IIISPECTION <br /> (when applicable) (whoe applicable) When applicable) <br /> fEf • I�O.00Ihr FEE • IOS.00/Ar FEE • IO5.00/hr { <br /> TOTAL DUE T <br /> drncE rst artr . <br /> n• c In I I9 a �., <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE Am,, 1011 CHECK WASH RCVO Dr DAiE P.ECEIVEo PERMIT . <br /> rYygaaR�INi WWfIVM!r6 uaNwuwprwp� <br /> • '�M fn19APtsron.�• <br />