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' .rr-u\ utu l.v L_uLHL NtAL 1 H U 1 1 l: 1 <br /> VROUND STORAGE TANK PR06RAN - FEE WORKSHE <br /> __._._.�._.____..... _.._.__...____.._.........._...___.______..__.__..._.._..._ __. ...._._........ <br /> ___..__._._...._.._._ <br /> (F FACILITY/Sf TE NAME FACILITY CONTACT NAME <br /> I..._ � M.r WITH AREA <br /> L STREET ADDRESS SITE PHONE 1 <br /> ........ <br /> Y CITY _ STAT IIP CODE t of Tanks <br /> �t C r4 ��� 9,-33 4 at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L...._...__ <br /> I MAILING ADDRESS Jq X_,�C L' APPLICANT PHONE WITH AREA cone <br /> _Dl <br /> N CITY .._ ..._. <br /> �- C STATE ZIP CODE TYPE of APPLICATION <br /> T !V �I ` CLOSURE, INSTALLATION. ETC.( G <br /> .........._..... <br /> ..-.._.__ ��.{�:._.__....__.... ...... <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A ..........__..__.____.......__.._._____..._� _____...__. _.__............_....__._..._ ___-..__.._....._...,_........_..._. .._...._.....______._....___.�_.._ .__..._.......___._.__.__..__ <br /> C 1986 1981 1988 1989 <br /> T ------ <br /> E <br /> _.. <br /> I 1 <br /> E TANK FEE _ $50.00 each TANK <br /> ......................_......._.._...... _..._._._.._............_._._.. ...__.._.................._........ ......_.................._...... _...._....._.........-..........._ _... _ __—_ _ .._.._...__._......._................... <br /> F t Tanks _ _ x $50.00 1986 1981 1988 1989 <br /> A (sul tipsy t by fee for <br /> C each year applicable) $ <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25281 for applicability) <br /> T 1 Tanks x $56.00 1986 1981 1988 1989 <br /> Y (enter aiount and year) <br /> __.._...__...._...._....__.__....__..._._._.__.__...___._._.___-_............._._..._.._..._ _..__.._.... _.__..._. ..,............. <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> ( ....-......._-_.._.---.--_._._ ......._._ ... ._...._ _...__'__.____.__... _._._......_.___-.._.__......_._.___. r...._-.«.._.__._..__.. .... -........ <br /> _... <br /> 0 CLOSURE FEE = 190.00 each TANK t Tanks _ _ x $90.00 f =" <br /> U ......._..... <br /> _ �._.. <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 $80.00 f <br /> ............_..._......................................................_____.___ _ _ _ _._.,.___.......__..._..._........ <br /> _...___. <br /> IP PLAN CHECK (Installation or Repair) <br /> L._........__._._..._......_.._..............._........_._._..._._____.__. __._.__.__._.._..._...___.___._..____.____..__...._._........_._._._._____.____...._.....__...__......_._..._....._.___... <br /> A <br /> N PLAN CHECK FEE = 130,00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> _......._.__._...-.__.._._.___ <br /> R TANK REPAIR FEE _ $110.00 each TANK 1 Tanks x $110.00 f <br /> E .------ <br /> P............-____----_----_--------------- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> 1 ..._..._.._...___._.....__------------__._...__ <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 110lhr FEE = 135.00/hr FEE _ $35.00/hr 1 <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> NummiINITN. Im . . i il"Pohmai mpkizz Il MEM$i.clusiNE NN1111 , 101110,01I I <br /> SWEEPS I COMP I LO( CODE DIST CODE) AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT I <br /> _._ .................._.._...._..... _._.._..._.__........._.. ...........__._.___ <br /> l A <br />