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w.vERGROUND STORAGE TANK PROGRAM - FEE WORKSHEL'o" <br /> ' f FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A y <br /> C S �IZ7 <br /> 1 <br /> L STREET ADDRESS � � SITE PHONE 1 (with Area Coded <br /> l29 <br /> T <br /> Y CITY STAA ZIP CODE t of TANK'S <br /> �j at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> 1 I (Closure, Installation, etc.-) <br /> A FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> I $ <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks x $50.00 r' f, 1986 1987 1988 1939 <br /> A (sultipIy i-by fee for <br /> C each year applicable) {L . , :-. Is ter- <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks .j x $56.00 /€ y 1986 1987 1988 1989 <br /> Y (enter iiount and year) -; <br /> C PERMANENT CLOSURE (Resoval or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK �� =; ? :.- t,- 1 Tanks %: _ z $10.00 S si r <br /> S ---- <br /> U <br /> 2 TEMPORARY CLOSURE (Only allowed one tiae for up to two years) <br /> E <br /> 1EMPORARY CLOSURE FEE = $80.00 each TANK 1 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 /> ¢— <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK 1 Tanks x $110.00 ; <br /> P <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, ainimu■ one hour to be paid on plan subsittal) <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/hr $ <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> S=m <br /> SWEEPS 1 COMP t LOC CODE7!!m <br /> UNT DUE AMOUNT RCVD CHEC /CASH RCVD BY DATE RECEIVED PERMIT II <br /> 354, -3 7ASO <br /> .,tar- -+ r rM.+rr- ..., �w,.,....•,,; .. <br /> 1' rYNil�:'j1.1t11 :il.. .l.1'f M',•. .�lK .�.1 Y./tf.s. nN,�1M.. 5,.+. <br />