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❑, I-1 LA . . .I�- . <br /> F1: pr.,y JUHaU n LVIi - <br /> UNII IND STORAGE E TANK PROGRAM - FEE WORKSHEET <br /> FACILITY CONTAC ME <br /> F FACILITYlSITE NAME t ve-s2 SRV1L$� /^c• <br /> T N M�1� <br /> ACaz4-D <br /> C <br /> [ SITE PHONE tl (with Area Code) <br /> L STREET ADDRESS J` ^,v Q� 7 2 p q 07 3 I O 9/3 <br /> [ "7 % . CODE 9 of TANK'S /'cIIP 00 o ' J <br /> ,4 1 <br /> T STATE / /�+ <br /> Y CITY CA lI at Site jwa 2 ( 1, 1 s1 <br /> Al <br /> APPLICANT CONTACT NAME <br /> A APPLICANTIBILLING NAMEI� GC VI�S�I� <br /> P F.' r" i/ t <br /> P R <br /> L 1 APPLIC NT PHONE 1 (with Area Code) <br /> I MAILING ADDRESS p <br /> C _2 Po C �+r <br /> A STATE LIP CODE TYPE of APPLICATION ��MO✓A I' <br /> N CITY �� a 0 (Closure, Installation, etc. <br /> T <br /> TOTAL <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br /> A 1986 1987 1988 1989 <br /> C $ <br /> T <br /> U <br /> E TANK FEE = $50.00 each TANK <br /> 1986 1987 1988 13A E E 1 V ED <br /> F # Tanks __ _ x 550.90 5 <br /> A t1tiply 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 25287 for applicability) <br /> 1 1986 1987 1988 EhI 90 ENTAL HEA T <br /> T # Tanks_____ x $56.00 5 <br /> LT <br /> Y (enter amount and year) <br /> C PERMANENT CLOSURE Renova or Closure-fn-place) $ Oy <br /> L t Tanks_, _ z $90.00 <br /> D CLOSURE FEE = 590.00 each TANK <br /> 5 <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to twa years) 5 <br /> E k Tanks_____ x 580.00 <br /> TEMPORARY CLOSURE FEE = 580.00 each TANK <br /> P PLAN CHECK (Installation or Repair) <br /> L 5 <br /> A <br /> N PLAN CHECK FEE = 530.00 each SUBMISSION/RESUBMISSION <br /> REPAIR 5 <br /> R t Tanksx $110.00 <br /> E TANK REPAIR FEE = 5110.00 each TANK <br /> P <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R SAMPLING <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTI N INSPECTION <br /> (when applicable) $ <br /> FEE = 530.00/hr <br /> FEE = 535.00/hr FEE = 535.00/hr <br /> TOTAL DUE 5 f r G`"U <br /> :OFFICE4SE ONLY <br /> 7z � <br /> # COMP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD DY DATE RECEIVED PERMfT i <br /> 9 d9egor <br />