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�••�•, ••�••,•, .�•., L.V4.R1L. RGHIr IN 11Ib I K1L:T <br /> `UGROUNB STORAGE TANK PROGRAM - FEEIWORKSHEA <br /> A T FACILITY/SITE NAME FACILITY CON NAME <br /> L STREET ADDRESS SITE PHONE I wITN AREA COOK <br /> T r ;+ <br /> Y CITY SST IIP CODE l i of Tanks <br /> at Site <br /> A APPLICANT/BILL( 6 NAME APPLICANT CONTACT NAME. <br /> P <br /> P 1 <br /> I MAILING ADDRESS APPLICANT PHONE I NITN AREA Cone <br /> N CITY STAT IIP CODE 15 TYPE of APPLICATION S4f;w�11,�` <br /> l� <br /> T �0! Irl-a"U", INSTALLATION. ETC. I <br /> r J r <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> 1986 1987 1988 1989 Ikk <br /> 1 <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks x 150.00 1986 1987 1988 1989 p <br /> A (multiply'i-by fee for <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH It SAFETY CODE Sec 252871for applicability) E <br /> I <br /> T I Tanks x $56.00 1966 1987 1988 `j 1989 <br /> Y (enter Snount and year) # <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) # i <br /> L I <br /> 5 <br /> CLOSURE FEE = 190.00 each TANK 1 Tanks__ x 190.00 !< <br /> U i <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> =TEKPORfYOSURE FE.E = $80.00 each TANK I Tanks x $80.00 $ i <br /> P PLAN CHECK (Installation or Repair) f <br /> L <br /> A j <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION ; <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each TANK I Tanks x $110.00 $ <br /> P ---E-- <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal)'' <br /> R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (V en applicable) (when applicable) (when applicable). <br /> FEE = 330.00Ihr FEE = $35.00Ihr FEE = $35.00/hr <br /> TOTAL DUE $ <br /> OFFICE USE ONLY I <br /> 4 � <br /> SNEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK ;WASH RCVD BY DATE RECEIVED PERMIT <br /> z <br /> 1RUR410 22 e�A1 70'" �t <br /> i <br /> €i <br /> F <br /> M1 4 <br />