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unu uunu 31UKAUC IMnh rKuuntin - rcc RUKN4111.41 <br /> F FACILITY/SITE NAME /' V FACILITY CON' nAME <br /> A ( � A-D <br /> I <br /> L STREET ADDRESS /� SITE PHONE I (with Area Code) <br /> Y CITY STATE ZIP CODE I of TANK'S <br /> 77 G k rO /✓ Cf! 5� 5' at Site TGJU�z ►. avo ,✓ <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> rr , <br /> P 1 R - i r" y; , ,Y j/ l u I*' -2S-r IG <br /> I MAILING ADDRESS APPLIC NT PHONE I (with Area Code) <br /> C O n o' C e{'7I Z <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION fV10+/4k— <br /> T C a-O (Closure, Installation, etc. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1981 1988 1989 <br /> I $ <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks x $50.00 1986 €981 1'388 198tzE E I VE D <br /> A (oultipfy f-by fee for <br /> C each year applicable) $ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks x $56.00 1986 1987 1988 E MIRO ENTAL HEA TFC <br /> Y (enter ii65nt and year) <br /> $ <br /> C PERMANENT CLOSURE ((Remova or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK I Tanks-..2- x $90.00 $ , 0­0 <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tiaE for up to tvo years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks x $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE = $110.00 each TANK I Tanks x $110.00 $ <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to he paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE = $35.00/hr FEE = $35.00/lir $ <br /> TOTAL DUE s f r <br /> OFFICE USE ONLY <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT I <br /> 371 � 9 µ1� i1o.°-2 ��dO0 �G7-7 <br /> vil <br />