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so JOAmuIN OOwTT PUNLIC NEALTR sBMcES . 9MRCwMENTAL WALTR G[vs20N <br /> `)ERf.R4)ID STORAGE TANK PROGRAM - FEE ILRKSNE' <br /> S F CILITY SIT NAME FA ILITY CONT NAME <br /> i �7roduc LVT.� CIL✓ CA2Q ✓ I�•trif- r I� <br /> E FACILITY ADORE ��`` S rTlEPH NE 0 with AREA CODE <br /> ah>✓1 Jt, � 9113-7337 <br /> A CI TY S A E ZIP CODE <br /> �S at of SITE KS <br /> v �✓.J� Tom//�iL— (� <br /> P APPLICANT/BILLING NAME AP LICANT CONT NAME <br /> L1C0 �trl>L a <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE 11 WITH AREA CODE <br /> A 12,117 <br /> T CITY <br /> /� STATE ZIP CODE TYPE of APPLICATION /s <br /> t ✓IDdes. o (Closure, Irotallati an, etc.7 (/ GWI O-VLt� <br /> TOTAL <br /> 1985 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED ([t ApplioahlUKXXX )Of XX S <br /> I <br /> V TANK FEE - 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 19911 <br /> C <br /> Tanks = 1986 1987 11988 1989 1990 1991 11992 1993 1994 1995 1996 <br /> F (=Ltiply 1 by fee for <br /> A each year applicable) I I I I S <br /> C <br /> [I TANK PENALTY FEES ASSESSED I XXXX XXXX I I I I S <br /> L <br /> II STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Cade, Section 25287 <br /> i <br /> T : larks z 556.00 1986 through 1990 1991 through 1996 <br /> (Entar amount and year) <br /> S <br /> I <br /> LIPERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK 1.0. Y(s) 2hO� �� <br /> Oj CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I k TANK(s)� 'X 5234.00 S 2 3 y.� <br /> S' <br /> U TEMPCRARY CLOSURE (PLan Review & Inspections) I TANK I.O. 0(s) <br /> EI TE.HPCRARY CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I B TANK(s)_ X 5234.00 = S <br /> P INSTALLATION PLAN CHECK (PLan Review & Construction Inspections)I TANK I.D. 0(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum 5 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.O. $(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) 0 TANK(s) _ X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION - 578.00/hr S <br /> II <br /> 5 <br /> C CONSULTAT[CN FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S <br /> < OFFICE USE ONLY <br /> SWEE?S 9 COMPUTER tl LOC CODE DIST CODE AMCUNT RECEIVED I CHECK */CASH RECEIVED 8Y DATE RECEIVE] <br /> a <br /> 3 <br /> S 3 <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />