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._ ® -t-"-,-•v • w#-At- hr-ALI M D i SITZ i Gl- C <br /> DERGROUND STORAGE TANK PROGRAM - FEE WORKS <br /> FACILITY/SITE NAME A FACILITY CONTACT NAME <br /> e <br /> 1 i L, <br /> L STREET ADDRESS _. <br /> I fiSITE PHONE 4 WITH AREA coo[ <br /> Y CITY STAT Ii <br /> P CODE 1 0l tanks <br /> A APPLICANT/BILLING NAME at Site <br /> P APPLICANT CONTACT NAME <br /> P --) <br /> 1 MAILING ADDRESS <br /> C APPLICANT PHONE 4 NIT" AN[A coo[ <br /> N CITY <br /> T S 1 ZIP CODE TYPE of APPLICATION <br /> �» C �r�3.' Ct.OMYAC0 IN'ITALLATION. [TC. <br /> FACILITY FEE = 4100.00 each SITE ADDRESS per YEAR <br /> TOTAL <br /> 1 1986 1981 1988 1989 <br /> 1 <br /> Vt <br /> I: TANK FEE = 450.00 each TANK <br /> F 1 Tanks x 450.00 1986 1981 <br /> A (sultipfy-('by tee far 1988 1989 <br /> C each year applicable) <br /> I 4 <br /> L STATE SURCHARGE = 456.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25281 for applicability) <br /> 1 <br /> T 1 Tanks x 156.00 1986 1981 �- <br /> Y (enter ieoiint and year) 1988 1909 <br /> 4 <br /> C PERMANENT CLOSURE ( ®ova -in-place) <br /> L <br /> 0 CLOSURE FEE. 90.0 NK <br /> S 1 Tanks ___ x 490.00 4 <br /> U <br /> R TEMPORARY CLOS <br /> E love a ti®e for up to two years) <br /> TEMPORARY CLOSURE FE �� each TANK <br /> 1 Tanks _ x 480.00 4 <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = 430.00 each SUBMISSION/RESUBMISSION <br /> 4 <br /> REPAIR <br /> R TANK REPAIR FEE = 4110.00 each TANK <br /> E 1 Tanks x 41 t0.00 4 cs <br /> P - - <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, .ini[un one hour to be paid on plan sub[ittal) <br /> 1 <br /> RrUNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION <br /> en appli(able) (vhen applicable) SAMPLING INSPECTION <br /> (when applicable) <br /> = 130.00/hr FEE = 435.00/hr <br /> FEE °43d.00/hr <br /> OFFICE USE ONLY TOTAL DUE 4 ` <br /> EEPS 1 COMP i LO CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BYTV DATE RECEIVEDI� <br /> PERMIT 4 <br /> y z 0I <br />