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g ---ArRGROUND STORAGE TANK PROGRAM - FEE 110RKSHEF,' <br />'-yr `F FACILITY/SITE HANE FACILITY Cfc HAKE <br /> A NS ST��ct4�j /-N c_ <br /> C <br /> I SITE PHONE # With Area Code) <br /> I STREET ADDRESS �3 2 y ✓E, <br />` T STATE IIP CODE 1 of TANK'S fJ� rf <br /> j Y CITY �L at Site v l <br /> A APPLICANT/BILLING NAVE APPLICANT CONTACT NAME <br /> P C— <br /> P <br /> L APP ICANT PHONE 1 (vith Area Code) <br /> IMAILING ADDRESS <br /> C q (p Z <br /> A STATE IIP CODE TYPE of APPLICATION <br /> N CITY i (Closure, installation, etc.) <br /> I T <br /> TOTAL <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br /> A 1986 1987 1988 1989 <br /> T by $ 1 Of <br /> I <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> ---------------------- <br /> F ITanks x $50.00 1986 1987 1998 1983 <br /> A (�ultipTy-T-by fee for $ 0 0 <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK, (see CA HEALTH I SAFETY CODE Set 25287 for applicability) <br /> I1386 1387 1988 1989 <br /> T 1 Tanks x $56.00 <br /> Y (enter mount and year) S <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> LI Tanks____ x $90.04 $ �� <br /> O CLOSURE FEE = $90.00 each TANK <br /> S I <br /> U <br /> R TEMPORARY CLOSURE (Only alloved one tia�e for up to Wo years) <br /> E I Tanks_____ x $80.00 $ <br /> . TEMPORARY CLOSURE FEE _ $80.00 each TANK <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A $ <br /> M PLAN CHECK FEE = $30.00 each SUBMISSIONIRESUBMISSION <br /> F REPAIR � <br /> E TRK REPAIR FEE _ $110.00 each TANY. <br /> # Tanks_____ x $110.40 $ <br /> P <br /> r A <br /> f 1 PIPING REPAiRICLOSUREIREMOVAL (Fees are per hours miniauo one hour to be paid on plan submittal) <br /> A R SAMPLING <br /> UNAUTHORIZED RELEASE EVALUATION INSPECTIONON INSPECTION <br /> When applicable) <br /> FEE = S35.00/hr $ <br /> FEE t $30.00Ihr FEE = $35.041hr D i <br /> t. TOTAL DUE $ <br /> polaaoo <br /> OFFICE USE ONLY <br /> 7FOSWEEPSCOMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED PERMIT I <br /> L 11 <br /> s <br /> a <br /> I <br /> i <br /> I <br />