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SAM "QUIN V Y PUBLIC HLALTII SERVICES - ENYIRON)'1£MTAL H, 0 DIVSIOII <br /> IA,�,�GRQAa) STC'41ACG uklix PRu01LUI - F£E LL'RXSD££.,1 <br /> 1 SI "ACILITY SITE NAME FACILITY CONTACT NAME. -- --_-- <br /> II <br /> r - _ __ �.Q✓aFP�/J�f�L/ <br /> Cl FACILITY ADDRESS <br /> SIT PHONE �.with AREA CODE <br /> �'- 3�r� GLVXf ✓ <br /> CITY ST TE ZIP CODE N of TANKS / <br /> P(- Gol; �5Z„Lat SITE <br /> Pi APPLICANT/BILLING NAME ADPL 1OAMi CONTACTN7 <br /> l ��- �y"�� cTt��e �7/o.c. a t/ <br /> ! Ci MAILINGADDRESS <br /> PPLI MY PHONE WWII TTY AREA CODE <br /> 1 tj CI7Y / ST TE ZIP CODE TYPE of APPLICATION <br /> /� (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) !100.00 <br /> I, A <br /> i C' <br /> �Oa /LYS /oo /Lim /OG s Jdp p <br /> Tj FACILITY PENALTY FEES ASSESSED (!} App((cebl e) xxxx X)OX <br /> i <br /> v TANK FEE • 150.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> M Tanks 1966 1987 1983 1)J9 1990 1991 1992 1993 1994 1995 1996 <br /> F (ml tiply 0 by fee for / <br /> Ceach year applicable) � J� �b /.. /� /?0 /;i $ mo <br /> 1 TANK PENALTY FEES ASSESSED Xxxx xxxx 5d L/J LJD /?O /7v S D «: <br /> L <br /> I STATE SURCHARGE • 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> tf a Tank f_� x 556.00 1986 through 1990 1991 Through 1996 -A <br /> (Enter amaxrt and year) <br /> G PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. N(s) <br /> L <br /> OFC'LOSURE FEE • $78.00/hour (3 hours minimm/TANK) Y TANK(s) X $234.00 $ <br /> S, <br /> UI TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. N(s) <br /> R <br /> E TEMPORARY CLOSURE FEE • S78.00/hour (3 hours mininKm/TANK) p TANK(s) X 5234.00 • S <br /> PI INSTALLATION PLAN CHECK Man Review & Construction Inspec(ions) TANK I.D. N(a) <br /> l`` 1 <br /> I Ai <br /> I NI PLAN CHECK FEE • 578.00/hour (8 hours minimm/FACILITY) $624.00 mini mAn $ <br /> R REPAIR FEE (Workplan Review & Construction Insxctions) nuv I-D pis• <br /> E P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimus/TANK) H TANK(s) X $234.00 • s <br /> 4 q - <br /> y <br /> R I TANK RETROFIT REPAIR FEE • 578.00/hour (3 hours min./FACILITY) = $234.00 minirmm 5 <br /> i — <br /> PIPING REPAIR FEE $78.00/hour,(3 hours m(nimm/FACILITY) = $234.00 mini mm 5 <br /> MI TRANSFER FEE • $20.00 UNAUTHORIZED RELEASE EVALUATION • S78.00/hr $ <br /> I <br /> S'-- <br /> C CONSULTATION FEE • $78.00/hr SAMPLING INSPECTION FEE • $78,00/hr <br /> TOTAL DUE f la q Z, <br /> FOR OFFICE USE ONLY <br /> n n s =n^�.,n;-- ,r isenaic®arbaacn6mrxa r i:3m ; vs a n;au xrtn�a6.,:6a6mea��^^- �,--yp <br /> SNEEPS MCOMPUTER ;5 LOC CODE DIST CODE AMOUNT RECEIVED CHECK M/CASX RECEIVED BY GATE RECEIVED <br /> -+- 'Y'ITixamimlmfi6:6i :=1 i4 rn6tRm nrt Fwmamm a:rR � —;n!!nmms�-rin�wmeem�acmav ,axeumeeummeenmxmmr=3rvxr9nn,:: <br /> uwu vnu. d-' "M.IIULtlh44JLi6;CxxQa�Rx6PWL6xmrlun Idr:Y81 m1.15.Iv.IluiV:W"1'116aaAxu..11A0�m pa3ltldh'IY0:061i.o!r A{Lt <br /> EH 23 032 (REVISED 11.1.92) Page 11 -R of <br /> 1 '3 <br />