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ENVIRUWMNIAL RULIR rrl{•r VA <br /> UNDERGamw STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NATE FACILITY CONTACT NA)R <br /> A L 611-60 <br /> CSTYE PHONE / ml <br /> th AREA CODE <br /> 1 FACILITY ADOR SS L GE �DA � �72 �Z22 <br /> L <br /> 1 � <br /> I clTy trTe :1�3 tot TANKS <br /> N� <br /> T at SITE <br /> A APPLICANT/BILLING MANE APPLICANT,CONTACT NAME <br /> P <br /> I MAILING ADDRESS APPLICANT PHONE / YITN AREA Com! <br /> C6 53 <br /> N CITY /STATE 11P COD! TYPE of APPLICATION <br /> T dnaDE5r0 ( 95. 5/ CLOSURE, INSTALLATION, ate. <br /> TOTAL <br /> A <br /> C 1906 19!17 1908 1909 1990 <br /> T ANNUAL FACILITY FE! (Prior to January 1, 1991) • $100.00 <br /> I 5 <br /> V <br /> E TANK FEE *50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F R Tw*m 1906 1907 1900 1909 1990 1991 1992 199! 19% 1 1995 1996 <br /> A (Futtlpty 0 lTfN (Or = <br /> C each year oMtfteble) <br /> 1 <br /> L StAt! VACNARr2 • *56.00 nM TANK (Duo every 5 years) tee Callfornle N L S Cod*, tectlon 25207 <br /> 1 <br /> N t Saris R S56.00 1906 through 1990 1991 through 1996 <br /> T (anter a.am ernd ynr) S <br /> PERMANENT CLOSURE (ReaOVel or Authorized Claurs-In-PIwe) TMK I.D. V0 <br /> C <br /> L CLOSURE FEE • 053.00 per hour (I hours alnlaw per TANK) t TANK(9) K 5159.00 S / S ,Qp•��p <br /> 0 <br /> S <br /> U TooORMY CLOSURE (A ern- In* persit, for revlw/Inspect Iam) TAIK I.D. t(a) <br /> R = <br /> F TEIWMARY CLOSURE FEE • A150.00 each TANK t TANK(e) _ 1( 5150.00 <br /> P PLAN CHECK (Install. Plan Revler L Construction Inape6tlars) TANK I.D. E(a) <br /> L <br /> A <br /> M24.00 Minion PLAN CHECK FEE - 553.00 per h (8 hours Nlnlnza per Facility) • <br /> alt 5 <br /> R REPAIR FEE (workplan review 8 eonetructlan Inspections) TANK I.D. t(e) <br /> E <br /> P SANK REPAIR IE[ • $53.00 per how IS hours alnlaaVtAMlq t TMK(q _ 11 $159.00 • f <br /> A <br /> I <br /> R PIPING REPAIR FEE • 153.00 per hew (3 hour minINA per faellltY • 5159.00) 5 <br /> n TRUSTER FEE • $20.00 IRI M NMItED RELE/UE IVALLIATION • 553.00/hr 5 <br /> i <br /> s <br /> C MRSULTATION FEE $53.00/hr SAMPLING INSPECTION FEE • $53.00/hr ! <br /> I <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> wiww:�. w ii�n`.ow_-6ii "www-Ti ".•f3"' �•ww'iix-"Ti, '-w' .moi A-i.^•wwiw'�•"" �apm <br /> *-r 7T a,�* rt; ,air _ <br /> �...»i:...•w..rww—�w•,..iwi GwSw iw mommommamme w,iiTi G.•iww,.•„w'i' ww:w wa�•,aw'w w'i M•ww•••wmTi7w�irriw-»... <br /> rw.rw.war—,NrrweawwrwwRwwwwnwwrwa>.w��warrwewwaiw wwRwawwwrwwwwwrwerwwFraRw.�w <br /> EN 23 02 (REV 4/8/911 it Peas 11 <br />