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SNI JOAOUIM COLN' UBLIC HEALTH SERVICES - ENVIRONMENTAL HEAL IVSIOM <br /> LIIDER`.A111D STORAGE TANK PROGRAM - FEE 1KDKSHEET �../ <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> II e f-ei5 /' w� l/a /1f LU / " [ s Oc/, �w <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> a x/ 30 5 . / ,- « t dv4 - -7 Ivo <br /> CITY STATE ZIP CODE # of TANKS <br /> P $�v G/C�v C4 -- 25— at SITE y <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I — L-rJz r s O GL v<— <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A /3 30 5 <br /> N <br /> T CITY Go ni STATE ZIP CODE TYPE of APPLICATION gL4 'Lca-� <br /> 4 Ft o7 Yo (Closure, InstaLLation, etc. <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> a!� 5 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX77 <br /> rni c� f <br /> I <br /> VTANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 9 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 7996 <br /> F (multiply # by fee for <br /> A each year applicable) U«( ��v �V lDov S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX I XXXX G!A (Q� �b'� �'(7 S - <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See CaLifornia H 8 S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) t <br /> c1 S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimua/TANK) # TANK(s) X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimus/TANK) # TANK(s) X 5234.00 = S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum $ <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY - <br /> ............._...._..__.._....._._...,::-:::::::::::-_:-::::,:::..____:_--.— ::-..._._.._........... : .—rs!e!_! !. ._._'—a!!:e! r=:!=:-:ii!ii!::=___.!--sig_::—i--!._..:-.°.:'.ti! <br /> ...................._............................ :::::::_::_:....:._._.._:.._..............._...::-::::::-:-:::-:::::-::::........_....__ .... . . ............ . <br /> _ ia:�.............................:_...._..:.iiia!:.=.-_.:i.::::_ :.. .:............. . ,.—__' __ -- :..:,r_,_::____-:. <br /> :iLa.;:--:-:: :!!t.!ea uL:L.:i::iii:iiiii:iiiiiir r:�rim�:Aa�®viii:! ,,:-:,:;:i_ai;:ic�i�! :Tis.-��T-...! !_—!.!-:..m.-..u:r!:--�,.r <br /> ii SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> 3 gg yyC�/ 333 s <br /> :::::::::::-:: !!::!_e�:'�!-ea-�r:!sm!!:!r:.=.a:c!!:a!ii:-: <br /> ::::-::::::-::::::::c•...:i3:ii!iJiS_a!ailuilfi0ie"uuiuvz�cia3'v33iii!iii.^.uu!2'v.�es:�ii:���"'ivi'a:i�iiP!!!iciSeeiiii3ii!:••_••-LTi:J!e_e!!eia�L:�-••c!ii:i�'!!!iiuiciic::r' `n'l ....._.. <br /> EH 23 032 (REVISED 11.1-92) Page 11 <br /> ` I <br />