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vim, r. �.. ... .....��... ��. ...�. � ... ..� ... �•.. .. .... .. �.. `. ..��.�... ..�.....��... <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />CLOSURE FEE = S261 I TANK <br />1996-1999 <br />FACILITY ADDRESS <br />SITE PHONE f VWTH AREA CODE <br />/5Z `rt51110 Al� <br />24 / -76-i <br />CITY <br />STATE 21P CODE <br />9 OF TANKS AT SITE <br />dvvli v •, <br />CA L <br />ZIP CODE <br />APPLICANT BILLNG NAME <br />APPLICANT CONTACT NAME <br />CLOSURE FEE = S261 I TANK <br />1996-1999 <br />APP <br />IMARANG ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />60x—S <br />o /✓ <br />CJCi — &>&o <br />CRY <br />I STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE_ <br />Closure Installation Repair Retrofit <br />If <br />SAMPLING INSPECTION FEE = S 87/ HOUR <br />5 ����' <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = S261 I TANK <br />1996-1999 <br />2000 <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $261 / FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />(Sr 70) x (r tmla) X pr o/ years applicable) <br />PIPING REPAIR FEE = $261 / FACILITY <br />120111 <br />$125 PER TANK AFTER FIRST TANK <br />SAMPLING INSPECTION FEE = S 87/ HOUR <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $8 / TAMC <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = S10 / FACILITY <br />PERMANENTCLOSURE <br />Removal or Permrlted Closure inNoe) <br />TANK ID # (s): <br />CLOSURE FEE = S261 I TANK <br /># TANKS X $261 = <br />TEMPORARYCLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $261 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK LINING REPAIR FEE = $261 / TANK <br /># TANKS X $261 = <br />TANK RETROFIT REPAIR FEE - $2611 FACILITY <br />CONSULTATION FEE = S 87/ HOUR <br />PIPING REPAIR FEE = $261 / FACILITY <br />_ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE = S 87/ HOUR <br />_ <br />UNAUTHORIZED RELEASE EVALUATION FEE = S 87 / HOUR <br />SAMPLING INSPECTION FEE = S 87/ HOUR <br />ALL FEES ARE BASED ON THE Sal HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE SO -LED TO APPLICANT. <br />OFFICF 113E ONLY <br />SERVICE REQUESTS FACIga ID AMOUNT RECENED CHECK a RECENED BY DATE RECEIVED <br />SR <br />EH 23 837 /REMISED 2 -"Il <br />