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UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C <br /> Z4� 14,11W <br /> T STREET ADDRESS SITE SONE I (with j(.ud) <br /> ll <br /> Y CITY STATE ZIP CODE 1 PfcTANK'�' <br /> FAC <br /> at7�1AME APPLICANT_O� NAM<co APPLICANT PHONE rwl rea Code) <br /> TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> A FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1906 1987 1988 1989 <br /> � <br /> �xw) v f <br /> O U <br /> E TANK FEE = 150.00 each TANK <br /> F I Tanks z $50.00 1986 1901 1988 1989 <br /> A (Rultip1y-I-by lee for <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = 156.00 each TANK. (see CA HEALTH I SAFETY CODE Sec 25281 for applicability) <br /> I <br /> T I Tanks z 156.00 19811 1907 1908 1909 <br /> Y (enter anoint and year) <br /> t <br /> C PERMANENT -- <br /> L _ ---— <br /> 0 CLOSURE F <br /> S RAMCOPI <br /> U FIELD ACCOUNT 342 <br /> R TEMPORARt PH. 916OX 10535 J- ^ <br /> E P.o. eox loza l71 SC}�1L')l <br /> TEMPORARt WEST SACRAMENTO, CA 95691 90-3632/1211 <br /> PAY TO THE <br /> ORDE Of <br /> ,- <br /> ---- DOLLARS i. <br /> M PLAN CHET � tTOL <br /> BINK OF NVI'VERCE <br /> .= <br /> /yam ..�o.CA s 14 <br /> R REPAIR MEMoQ��UI Off( <br /> [ TANK REP <br /> A <br /> I PIPING <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION ,. SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = 130.00/hr FEE _ $05.00/hr FEE _ $35.00/hr <br /> $ <br /> OFFICE USE ONLY TOTAL DUE <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CH CK /CASH RCVD BY GATE RECEIVED PERMIT I <br /> 3v> �`7 <br />