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••� .,+ :� c.tea.r,� r1G rlL lfx UAL lmaul <br /> RBROUND STORAGE TANK PROSRAM - FEE WORKSHE <br /> rF FACILITY/SITE NAME <br /> , s? � I��`n ` r0 FA ILITY CONp�T NAME <br /> C/•�t t �'d� , f r c . �o►d+J <br /> L STREET ADDRESS �� I� <br /> T <br /> T 'Y Gem SITE PH NE 1 (with Area Code <br /> Y CITY ) <br /> l <br /> c�]OTATE ZIP CODE f of TANK'S <br /> A APPLICANT/BILLING NAME 1 a0 at Site <br /> Pf AP LICANT CONTACT NAME <br /> L `( E N� �plofJnL, It4C - <br /> II MAIL ADDRF�S X 3 P41) �F-t f L-t. l A <br /> APPLICANT PHONE 1 (with Area Code) <br /> N CITYC a_ Lf v _ <br /> T d d vKTUtJ CA "- I of APPLICATION ((�� <br /> Sa'�Ob <br /> A (Closure, Installation, etc.) �.1.Ocw12f� <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br /> C TOTAL <br /> T 1986 1981 1988 1989 <br /> 1 <br /> V <br /> E TANK FEE _ $50.00 each TANK $ <br /> F f Tanks _ x $50.00 1986 <br /> A (multiply f_by fee for 1981 1988 1989 <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25181 for applicability) $ <br /> 1 <br /> T t Tanks x $56.00 1986 <br /> Y (enter ii356t and year) 1987 1988 1989 <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK <br /> S f Tanks x 190.00 Q <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> iWORARY CLOSURE FEE = $80.00 each TANK <br /> 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 <br /> f <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK <br /> P 1 Tanks_ x $110 $ <br /> A .00 <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 <br /> (when applicable) INSPECTION SNMP <br /> FEf = (30,00/hr INSPEECTICTI <br /> ON <br /> FEE = $35.00/hr FEE = $35.00/hr <br /> OFFTCF USE ONLY TOTAL DUE $ <br /> SWEEPS t COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVO C C i CASH RCVO BY DATE RECEIVED PERMIT 1 <br /> �03� ?lvT2 gL U/ 1 `f 2 ASO ` 50 — <br /> / iSl <br />