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I CT <br />ERGROUND STORAGE TANK PROGRAM - FEE NORKSH <br />f FACILd Y/SITE NAME <br />A <br />FACILITY CONTACT NAME <br />I <br />C- <br />_ <br />e— <br />L STREET ADDRESS <br />f Y �. <br />J I <br />SITE PHONE 1 YITH AREA coca <br />�' <br />Y CITY <br />STAT';MTNTACT <br />anks <br />te <br />A APPLICANT/BILLING NAME <br />P <br />ONAME <br />I MAILING ADDRESS <br />"� <br />At: <br />APPLICANT PHONE 1 u1Ta AREA <br />coot <br />- <br />STAT <br />ZdP C00 TYPE of APPLICATION <br />!N®TALLAfICH, <br />aTC. <br />A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br />C <br />TOTAL <br />T <br />1 <br />1986 <br />1987 <br />1988 <br />1989 <br />V <br />E TANK FEE = 150.00 each TANK <br />S <br />f 1 Tanks x 150.001986 <br />A (®ultipfy"I'Dy fee for <br />1987 <br />1988 1989 <br />C each year applicable) <br />- <br />1 <br />L STATE SURCHARGE = 156.00 each TANK <br />1 <br />(see CA HEALTH i SAFET Y CODE <br />Sec 25287 for applicability) <br />1 <br />T I Tanks z 156.00 <br />Y (enter iiount and year) <br />1986 <br />1981 <br />1988 <br />1909 <br />t • <br />(Re®oval or Closure -in-place) <br />= 190.00 each TANK <br />FTEMOSURE <br />1 Tanks .00 <br />OSURE (Only allowed one tine for up to two years) <br />OSURE FEE = 180.00 each TANK <br />1 Tanks <br />P <br />PLAN CHECK (Installation or Repair) <br />L <br />A <br />N <br />PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION <br />1 <br />REPAIR <br />R TANK REPAIR FEE = s110.00 each TANK <br />E <br />P <br />1 <br />Tanks__x $110.00 <br />s <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, a(niaua one hour <br />to be paid on plan subaittal) <br />R UNAUTHORIZED RELEASE EVALUATION <br />(when applicable) <br />CONSTRUCTION INSPECTION <br />SAMPLING INSPECTIO N <br />(when applicable) <br />(when applicable) <br />FEE = 130.00/hr <br />FEE = 435.00/hr <br />FEE = 135.00/hr <br />s <br />OFFICE USE ONLY <br />TOTAL DUE <br />s <br />Mimi <br />SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD <br />CHECK I,CASH RCVD BY DATE RECEIVED <br />PERMIT 1 <br />