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DERAROUND STORAGE TANK PROGRAM - FEE OORKSO <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C C0v �zv /gej ALEx �IWF/NG <br /> L STREET ADDRESSSITE PHONE t (with Area Code) <br /> 1 / s /5 0 0 11'M1A) 7-RS6T a20 ash - 03 <br /> T <br /> Y CITY n STATE iJ� CODE t of TANK'S <br /> rfyP /TE OeLl r L qu�. �533/o at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> F <br /> -06IV — mi rk/ Y- ✓ ejr rnEn/Ts (�1IAcT�o2 pEN/G <br /> I MAILING ADDRESS APPLICANT PHONE t (w t Area Code) �?O 9 <br /> C 3900 ✓ e / mf A✓ I/Vi /- TE OE /V/ 0 5a l-8 s <br /> N CITY STATE ZIP CODE ITYPE of APPLICATION <br /> T CQ�S%O CAL/� 9S3S� (Closure, Installation, etc.) 06vJ141-16- <br /> A <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> I f <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F t Tanks z $50.00 1986 1987 1988 1989 <br /> A (multipTy-i'6y fee for <br /> C each year applicable) $ <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks s $50.00 1986 1981 1988 1989 <br /> Y (enter enount and year <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK <br /> S t Tanks''L_- z $90.00 f 190. 00 <br /> U <br /> P. TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK t Tanks z $80.00 $ <br /> P IL PLAN CHECK (Installation or Repair) <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR <br /> R <br /> E TANK REPAIR, FEE _ $110.00 each TANK <br /> P t Tanks z $110.00 f <br /> A <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 = $35.00/hr $ <br /> TOTAL DUE Is <br /> OFFICE USE ONLY <br /> SNEERS 1 COMP t IOC CODE OIS1 CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT t <br /> 143(e cwk 0?- � _ <br />