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.:+.,,v j UAwU ll Iv LUCAL HEALTH D I S)'R I CI- <br /> - GROUND STORAGE TANK PROGRAM - EEE NORKSHEO <br /> f fACILITYISITE NAME <br /> • A ,� 1 FACILITY CONTACT NAME <br /> •N �C-t( . , � -��� .Com/". , �,.� <br /> L STREET ADDRESS. / P SIZE PHONE 1 YIiN ANCA cool <br /> T <br /> Y CITY STAT ZIP CODE 11 of Tanks <br /> A APPLICANTIBILLING NAME <br /> P 1APPLICANI CONTACT NAME <br /> L , <br /> ! MAILING ADDRESS <br /> C APPLICANT PHONE 1 rlrn A11[A coat <br /> A <br /> M CITY a <br /> I f� 7? STAT IIP CODE TYPE of APPLICATION <br /> CLas U11[, 1"@TALLA11ON, are. , „+zG•,t'� <br /> FACILITY FEE = (100,00 each SITE ADDRESS per YEAR <br /> A TOTAL <br /> C 1986 1981 <br /> 1 1998 1989 <br /> v 1 <br /> E TANK FEE = 150,00 each TANK <br /> F 1 Tanks _ r 150.00 1906 1981 1988 <br /> A feultiPT I by fee for 1989 <br /> C each year apPli(able) � <br /> L STATE SURCHARGE = 156,00 each TANK (see CA HEALTH R SAFETY CODE Sec 25281 for applicability) <br /> I <br /> T 1 Tanks r 156.00 1986 1981 1988 <br /> Y (enter mount and year) 1989 <br /> 3 1 <br /> C PERMANENT CLOSURE (Removal or Closure-In-place) <br /> L <br /> 0 CLOSURE FEE a 190,00 each TANK <br /> S 1 Tanks r 190,00 1 <br /> U - - - <br /> R TEMPORARY CLOSURE (Only ailoved one time for up to Ivo years) <br /> 1: <br /> TEMPORARY CLDSURE FEE = 180,00 each TANK I Tanks --_PA 1 <br /> P PLAN CHECK (Installation or Repair) <br /> A 6 1990 <br /> N PLAN CHECK FEE : 130.00 each SUBMISSIONIRESUBMISSIONSAN Jf3pRUIN 1'Cil�s <br /> RU HEpLTt9 SF.i3VI ON <br /> REPAIR <br /> R TANK REPAIR FEE : 1110.00 each TANK <br /> P I Tanks r 11I0.00 1 <br /> A PIPING REPAIR/CLOSURE/REMOVAL (fees are per hour, minimus one hour to he paid on plan submittal} <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (vhen applicable) Men applicable) Ivhen applicable) <br /> FEE = 130,001hr FEE = 135.40/hr <br /> FEE = 135,001hr 1 <br /> TOTAL DUE 1 <br /> OEfItI USE OILY <br /> SREEPS 1 COMP 1 LOC CODE MM CHECK WASH RCVD BY DATE RECEIVED PERMIT 1 <br /> 7 F7 <br /> • 0 <br />