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SAM JOACUINPISLIC HEALTH SERVICES - ENVIRONMENTAL � DIVSICM <br /> �>m STCRAGE TANK PROGRAM - FEE UORKS7�-cT <br /> SI FACILITY SITE NA7ME�• FACILITY CONTACT NAME <br /> I <br /> T <br /> E FACILITY ADORESS S1 PHONE 3 with AREA COLE <br /> A 2or Zo9� S�/- 09 <br /> CITY STATE ZIP COCE 0 of TANKS <br /> A --UG -TD at SITE <br /> P <br /> P APPLICANT/BILLING NAM APPLICANT CONTACT NAME <br /> L TD / <br /> I <br /> C MAILING ADDRESS APPLICANT PHONEY YITH AREA COLE <br /> A <br /> N <br /> T CIT7 —STATE ZIP CODE TYP f APPLICATION <br /> S p /drt1 v� � Zp Clos tat Lation, eta.) <br /> IGTAL <br /> 1986 1987 1988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to Jacxsry I, 1,991) = $1100.00 <br /> A XXXX XXXX I I S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If AmtiC3bte) I xXXX wx 5 <br /> I <br /> V TANK FEE 550.00/TANK (Prior zz Jan airy 1,1991) 5170/TANK (After January 1, 1991) <br /> e_ <br /> Y Tanks = 1986 11987 11988 1198 992 9 11990 11991 11 1943 11994 11995 11996 <br /> FI (multiply f oyfee for <br /> A each year applicable) XXTL I I I I I 11.-777�18 I S 17 0 <br /> I TANK PENALTY FEES ASSESSED X= "� I I I I !o S [ 8 <br /> L <br /> I r.ATE SURCHARGE = S56.G0 each TANK C.z every 5 years) See CaLifornia H A S Code, Section 25287 <br /> T <br /> TI : Tanks_ x 556.00 :G°S through 1990 1991 through 1996 <br /> (Enter amouac and year) <br /> S <br /> L. PERMANENT CLOSURE (Removal or Authcri= Ctosure-in-Placa) I TANK E.G. X(S) <br /> 5{ CLOSURE FEE - 578.00/hour (3 hours sininaVTANK) I TANK(s) X 5234.00 = S <br /> U iE77POl I R42Y CLOSURE (Plan .Review A Inspe_^_:ons) TANK I.D. $(S) <br /> R <br /> TEMPCRARY CLOSURE FEE - 578.00/hour L• =a's minimum/FACILITY) I 5234.00 minimum S <br /> `I INSTALLATICH PLAN CHECK (Plan Review A = sstruction Inspections)I TANK I.D. i(s) <br /> A <br /> Al PLAN CHECK FEE - 578.00/hour (8 hours Minima/FACILITY) - 5624.00 minima S <br /> R REPAIR FEE Workplan Review i Cont,.:;..= Inspectiotn) I TANK I.D. 3(s) <br /> E <br /> P TANK LINING REPAIR FEE - S78.00/hour G hours minimum/TANK) TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE - 578.001hor C3 hours min./FACILITY) = 5234.00 minima S <br /> z <br /> PIPING REPAIR FEE = S78.00/how <3 ho.- ainim m/FACILITY) = SZS4.00 minima S <br /> M TRANSFER F=EE = 520.00 WITMORIZ=D REIN -.VALUATION - 578.00/hr S <br /> I <br /> S <br /> Cf CONSULTATION FEE = 578.00/hr I >AMT_!NG INSPECTION FEE S78.00/hr 5 <br /> TOTAL OLA: S 7 . Co <br /> FOR OFFICE USE OLLT <br /> SYEEPS COMPUTER I LOC CODE GL`T C(LE I AMOUNT REI=IVEO CHECK :/CASH RECEIVED 3T I GATE RECE-IVEO <br /> = I I I 15 I I I <br /> .H Z3 GM (REVISDr. 10-28-93) Page 11 <br />