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' #A NOERGROUNO STORAGE TANK PROGRAM - FEE WORK <br /> y F FACILITY/SITE NAME <br /> A FACILITY CONTACT NAME <br /> S <br /> L STREET ADDRESS SITE PHONE i (with Area Code.' <br /> r126 (,U <br /> Y CITY ST ZIP CODE I of TANK'S <br /> at Site <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAILING ADDRESS <br /> C APPLICANT PHONE I (with Area Code) <br /> A <br /> N CITY <br /> I STATE IIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR. TOTAL <br /> C 1386 1887 1988 1889 <br /> T <br /> I <br /> V 5 <br /> E TANK FEE = $50.00 each TANK <br /> F i Tanks x $50.00 ft . 1986 1987 1988 19313 <br /> A (multiply I-by fee for <br /> r C each year applicable) -- f <br /> L STATE SURCHARGE = S56.00 each TANK '(see CA HEALTH Z SAFETY CODE Sec 25287 for applicability) <br /> I I <br /> T I Tanks x 556.00 .i 1986 1987 1,388 1989 <br /> Y (enter amount and year)I <br /> FPERMANEXT LOSURE (Removal orClosure-in-place) <br /> = 590.00 each TANKr�/`� a4_ :Fµ I Tanks -- x 530.00- -- 5 <br /> 2 TEMPORARY CLOSURE (Only allowed one tiae for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks x $30.00 <br /> --------------- <br /> S <br /> P PLAN CHECK (Installation or Repair) <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 <br /> P 1 Tanks x $110.00 5 <br /> I PIPING REPAIR/CLOSU2E/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = $30.00/hr FEE = 535.00/hr5 <br /> - o� <br /> FEE - <br /> TOTAL DUE 5 <br /> OFFICE USE OAty <br /> SWEEPS I COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHEC /CASH RCVD BY DATE RECEIVED PERMIT I <br />