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77 <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />(F1F6CgITY/SITE <br />NAME • <br />FACILITY CONTACT t � <br />C <br />1386 )'387 1988 1989 <br />T <br />I <br />LST <br />EET 00➢.ESS <br />SITE PHONE I WITH AREA CODE <br />P <br />TEAPORARY.CLOSURE (Only allowed one time for Up to two years) <br />E <br />T <br />Y <br />CI T TE <br />IIP CODE <br />J <br />I of Tanks <br />at Site �2 <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT N MA E _ <br />P <br />P <br />-- <br />A <br />L <br />I <br />MAILING ADDRESS APPLICANT PHON 1 WITH AREA CODE <br />4 +e �aaC/ L/ iia <br />a <br />CI TA E IIP CODE TYPE of APPLICATION <br />T <br />CLOOURE. INSTALLATION. ETC. <br />- <br />FACILITY. -FOE' 5100.0 each SITE ADDRESS per YEAR <br />TOTAL <br />C <br />1386 )'387 1988 1989 <br />T <br />:- ` - — <br />TANK.P.EPAIR FEE _ $110.00 each TANK <br />Ip�.4 :;i1� 11 u rll hr <br />P <br />TEAPORARY.CLOSURE (Only allowed one time for Up to two years) <br />E <br />TANK FEE _ $50.00 each TANK <br />F <br />f Tanks x $50.00 <br />1386 <br />1381 <br />1388 <br />)38'3 <br />PIPING P.EPAIP./CLOSUP.E/REMOVAL (Fees are <br />per hour, minimum one hour to be <br />A <br />ImultipT1 by fee for <br />i <br />R <br />UNAUTHORIZED RELEASE EVALUATION <br />(when applicable) <br />CONSTRUCTION INSPECTION <br />(when applicable) <br />SAMPLING INSPECTION <br />(when applicable) <br />C <br />each year applicable) <br />FEE =.$35.00/hr <br />$ <br />I. <br />LSTATE <br />SURCHARGE '= $56.00 each TANK (see CA HEALTH 4 SAFETY CODE Sec 25281 for applicability) <br />I <br />T <br />I''Tan ksa_ x`$56.04 <br />1386 <br />— <br />1987 <br />1388 <br />1383 <br />Y <br />(enter amount and year) <br />— <br />C <br />PERMANENT-CLOSUP.E.(Removal or Closure -in-place) <br />d II k® <br />I II <br />0 <br />CLOSURE FEE each TANK 1 Tanks C]! 1 $90.00 f' <br />U <br />,-:;$30.00 <br />TANK.P.EPAIR FEE _ $110.00 each TANK <br />Ip�.4 :;i1� 11 u rll hr <br />P <br />TEAPORARY.CLOSURE (Only allowed one time for Up to two years) <br />E <br />E <br />" <br />i�l�, l�l�ll)RI .I. <br />,!III L I1IIi �h <br />TEMPORARY CLOSURE FEE = $80.00 each TANK <br />I Tanks------ x t90.00 <br />$ "' <br />OFFICE USE OILY <br />REPAIR . .. <br />d II k® <br />I II <br />(.1111 l <br />11111AI I <br />I � I <br />A`�9 <br />TANK.P.EPAIR FEE _ $110.00 each TANK <br />Ip�.4 :;i1� 11 u rll hr <br />H <br />PLAN 11 CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br />f <br />OFFICE USE OILY <br />REPAIR . .. <br />d II k® <br />I II <br />(.1111 l <br />11111AI I <br />I � I <br />R <br />TANK.P.EPAIR FEE _ $110.00 each TANK <br />Ip�.4 :;i1� 11 u rll hr <br />f Tanks - <br />1 $110.00 <br />$ <br />E <br />" <br />i�l�, l�l�ll)RI .I. <br />,!III L I1IIi �h <br />ti111JIM411111 �L i IIIUf <br />k!Ei.•{I,:g1 <br />P <br />A <br />PIPING P.EPAIP./CLOSUP.E/REMOVAL (Fees are <br />per hour, minimum one hour to be <br />paid on plan submittal) <br />i <br />R <br />UNAUTHORIZED RELEASE EVALUATION <br />(when applicable) <br />CONSTRUCTION INSPECTION <br />(when applicable) <br />SAMPLING INSPECTION <br />(when applicable) <br />FEE _ $30.00/hr <br />FEE =.$35.00/hr <br />FEE = <br />$35.00/hr <br />f <br />TOTAL DUE <br />$ <br />OFFICE USE OILY <br />23 U3Z KtVlbtu lu5m <br />lf'I'Il <br />I rl <br />d II k® <br />I II <br />(.1111 l <br />11111AI I <br />I � I <br />IT I VIII I JR01I0 <br />IH I tllll`Ill, J'Il IM (IIII <br />Ip�.4 :;i1� 11 u rll hr <br />1111 'I'I <br />11'19. ,u''.J' <br />i�l�, l�l�ll)RI .I. <br />,!III L I1IIi �h <br />ti111JIM411111 �L i IIIUf <br />k!Ei.•{I,:g1 <br />23 U3Z KtVlbtu lu5m <br />