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tAYEERGROUND STORAGE TANK PROGRAM - FEE YORKSHEEr" <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A y <br /> C S 6�IZf <br /> L STREET ADDRESS /,' SITE PHONE t (with Area Codei <br /> I �f <br /> T <br /> Y CITY STWf IIP CODE 1 of TANK'S <br /> j� at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> C <br /> A <br /> N CITYSTATE IIP CODE TYPE of APPLICATION <br /> T (Closure, Installation, etc.) <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1581 1988 1989 <br /> T <br /> 1 $ <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks _ x $50.00 1986 1987 1988 1939 <br /> A (multiply I-by fee for _ --- <br /> C ead year applicable) ` <br /> c.. <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T t Tanks x $56.00 1986 1981 1988 1989 <br /> Y (enter iiuziit and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> S CLOSURE FEE = $90.00 each TANK 1 Tanks_ ___ z $90.00 f <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks x 480.00 $ <br /> L PLAN CHECK (Installation or Repair) <br /> A -- <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ <br /> r <br /> $ REPAIR <br /> R <br /> E TANK REPAIR FEE = $110.00 each TANK t Tanks z $110.00 $ <br /> P <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 SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE = 435.00/hr $ <br /> TOTAL DUE 4 <br /> OFFICE USE ONLY <br /> SUEEPS 1 CAMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHEC /CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> Of 32v 35(,� 3 10 7aSd yp� <br /> �e:Y .a ' :r 1'�MI'.r.., •�r.. • .�� wn� ,�,:yn+.n .i . s. - �.:a <br />