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UNPcR6ROUND STORAGE TANK PKUbKAM - ILL MOKKbhLL1 • <br />' w <br /> P FACILITY/SITE NAME FACILITY CONTACT NAME <br /> I SITE PHONE 1 with Area Code) <br /> L STREET ADDRESS -- 7y0 <br /> T SATE ZIP CODE 1 of TANK'S <br /> Y CITY 7D/JA at Site <br /> A APPLICANTIOILLING NAME APPL ANT CONTACT NAME <br /> P d� /YI �) IL'f�A�c /✓ /[.J,TOnJ <br /> F <br /> L APPLICANT PHONE 1 (with Area Code) <br /> I MAILING ADDRESS / a5-C24- 96--S3 <br /> C4/_3/ <br /> / Sj(�TE I CODE <br /> N CITY / TYPE of APPLICATION n <br /> T c)AE )t S%TJ (J� 'j73� l (Closure, Installation, <br /> TOTAL <br /> FACILITY FEE = 4100.00 each SITE ADDRESS per YEAR <br /> A 1986 191, 1988 1909 <br /> C <br /> T $ <br /> - 1 <br /> V <br /> E TANK FEE = 450.00 each TANK <br /> F 1 Tanks _ _ s (50.00 1986 1981 1988 1989 <br /> A (sultipli I by fee for <br /> C each year applicable) <br /> I. <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25281 for applicability <br /> 1 <br /> T 1 Tanks s 156.00 1986 1981 198A l98 <br /> Y (enter iiount and year) S <br /> i <br /> F E <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L 1 Tanksfx 490.00 $ U. O (� <br /> O CLOSURE FEE = $50.00 each TANK <br /> 5 <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tine for up to two years) — <br /> E 1 Tanks_____ s 580.00 $ <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK <br /> P PLAN CHECK (Installation or Repair) <br /> l <br /> A $ <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> R 1 Tanks_____ z $110.00 $ <br /> E TANK REPAIR FEE _ $110.00 each TANK <br /> P <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minim one hour to he paid on plan submittal) <br /> RSAMPLING <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION <br /> INSPECTION <br /> (when applicable) <br /> FEE = 430.00/hr <br /> FEE _ $35.00lhr FEE = 435.00/hr $ <br /> TOTAL DUE <br /> OFFICE USE ON(Y Y <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED IPERMIT 1 <br /> �o qo — /345 a d1�89 <br /> i <br />