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-'ERGROUND STORAGE TANK PROGRAM - FEE NORKSHE = + <br /> AF-FACILITY/SITE NAME � <br /> FACILITY CONIA ARE 21 �{Z� <br /> C <br /> I <br /> SITE PHONE <br /> L STREET ADDRESS 1 <br /> I i1tTN ARRA CppR <br /> T f <br /> Y CITY <br /> STAT IIP CODE I of Tanks <br /> at Site <br /> P APPLICANT/BILLI G NAME <br /> APPLICANT CONTACT NAME <br /> P i <br /> I MAILING ADDRESS <br /> A 0`�� {�'r�trr APPLICANT PHONE <br /> wrTH AREA CODE <br /> c <br /> N CITY <br /> T { STAT �SIEof oeuRe.At11RLTA�LATOpON� ETC.�I �' J <br /> I <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR <br /> A TOTAL <br /> C 1466 1987 1988 1989 <br /> T <br /> V <br /> E TANK FEE = 150.00 each TANK <br /> F I Tanks x $50.00 1986 1987 1988 1989 i <br /> A (multipTy"f-by lee for <br /> C each year applicable) d <br /> 1 f <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25287 for applicability) i <br /> ( <br /> T I Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter a�iouF�t and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L F <br /> 0 CLOSURE FEE = $10.00 each TANK 1 Tanks <br /> S <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 I Tanks x $80.00 $ <br /> A <br /> P PLAN CHECK (installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RE5UDMISSION 1 j <br /> REPAIR } <br /> I <br /> R TANK REPAIR FEE = $110.00 each TANKS <br /> 110.00 <br /> t Tanks x 1110.00 1 <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> When applicable) (when applicable) When applicable) S x <br /> FEE = 130.00/hr FEE = 135.00/hr FEE _ $35.00/hr 70 <br /> TOTAL DUE fo a <br /> OFFICE USE ORLY 70. <br /> W11111911101111 UMMIMMr <br /> SNEEPS I COMP I ZLOCCODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD.DY DATE RECEIVED PERMI11 MM T 1z LA(IRR l041A 70,x' <br /> i <br />