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. .. ..t.-.- ._ .� �v r H i. I'll h.I'l L. 1 TT L � �•(�L� � <br /> NDERGROUND STORAGE TANK PROGRAM • FEE WORK49-- _r1 7 <br /> Q <br /> If FACILITY/SITE NAME FACILITY CONTACT NAME <br /> �a car C- <br /> L STREET ADDRESS <br /> �Z SITE PHONE 1 <br /> NITN ARE,% coot <br /> l C <br /> T � <br /> Y CITY STAT IIP CODE 1 of Tanks <br /> at Site <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> P TI <br /> L c ten. TUC_ <br /> I MAILING ADDRESS,-�� `` \ Cal <br /> `a APPLICANT PHONE 1 M1TM AR[A coot <br /> ::: {'ISI : CT ILP CODE ORANSLON611 O -4 CSc� VUESITALAON, nc. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR <br /> A TOTAL <br /> 1 1986 1987 1988 1989 <br /> 1 <br /> V 1 <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanks x (50.00 1906 1981 <br /> A (sultipfy I-by fee for 1988 1989 <br /> C each year applicable) <br /> I 1 <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> 1 <br /> T 1 Tanks x 156.00 1986 1907 <br /> Y (enter Mount and year) 1988 1909 <br /> MEN I t <br /> EPIORSIUARNE" <br /> CLOSURE (Removal or Closure•in-place) <br /> FEE = 190.00 each TANK 1T x l •'04 <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) E <br /> VIRUN- <br /> E <br /> TEMPORARY CLOSURE FEE = 180,00 each TANK <br /> 1 Tanks x 180.00 1 <br /> EA CHECK (Installation or Repair) <br /> CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION <br /> 1 <br /> REPAIR 7 <br /> R TANK REPAIR FEE = 1110.00 each TANK <br /> E 1 Tanks 3 , x 1110. <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan 11111 <br /> l <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION <br /> (when applicable) (when applicable) SAMPLING INSPECTION <br /> _ (when applicable) <br /> FEE = 130.00/hr FEE = 135.00/hr <br /> FEE = 135, /hr , 1 <br /> OFFICE USE OILY `. TL DUE 1 � � 0C2 <br /> i <br /> i l <br /> SWEEPS 1 COMP i LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK IICASH KCVO DATE RECEIVED PERMIT 1 <br /> � m ',� ° �IlVlllliw;llll 6111"ll'Ifll'11161�1111(1") <br />