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SMI JOHOUIN CC.. if RELIC HEALTH SERVICES - MIROMENTAL IS A DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET" <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> a <br /> A CITY STATE ZIP CODE # of TANKS <br /> P a[ SITE <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 2100.00 1986 1987 1988 1989 1990 <br /> A XXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicabte) XXX% X%XX 2 <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 991 1992 1993 1994 1995 1996 <br /> F (multiplyp byby fee for <br /> A each year applicable) XXX% XXX% S <br /> C <br /> I TANK PENALTY FEES ASSESSED X%XX XXX% ;"_�� ��i✓ f <br /> L /;, �t <br /> I STATE SURCHARGE - 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks X 556.00 1988 through 1990 1991 through 1996 <br /> (Enter Wwt and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Plate) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 278.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = i <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> P INSTALLATION PLAN CHECK (Plan Review a Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 578.00/hour (8 hours minimm/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 278.00/hour (3 hours minimm/FACILITY) = 2234.00 minimum f <br /> M TRANSFER FEE = 220.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr f <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE - $78.00/hr Hsi <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> 2 <br /> iH!159_3c 'vrNu ��'I'acsxau:q!T.8fiM7HflH'8121'miiWH _ <br /> JL::ii 'mHiiP ^ 2uaticJi <br /> EH 23 032 (REVISED 6.21-93) Page 11 ,� <br />