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B FACILITY sFT[ rAFe ,..',_,;:�.� - tr 1 , .r.�:: - .. , .: r <br /> 1 - • , :i? i <br /> r <br /> E FACILITY ADDRESS Slit PHONE '+� <br /> W f ad MAUA$A i70D1(" s {f � <br /> T G� ` <br /> CITY STATE ZIP CODE N of TANKS <br /> T/_ .3 et SITE <br /> A <br /> P APPLICANT CONTACT <br /> { �R ,1lPP�IWIT/ lLIN6 <br /> ' I APPLICANT PHONE I/ WITH AREA CODE <br /> CMAID G ADDRESS <br /> A <br /> R - STATE IP CODE TYPE of APPLICATION <br /> I S1JX (closure, irlstallstion, etc.) <br /> TOTAL <br /> 1986 1967 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to 2401 1, 1991) • 5100.00 )ow xw 100 /00 '/DO $3oo <br /> A - <br /> c xxxx xx10( D D <br /> T FACILITY PENALTY.FEES ASSE$$ED.(if.Appliaable) 1 /DO Ipp 5 U <br /> I 5170/TANK (After January 1, 1991) <br /> V TANK FEE OW :�(Prlor to January 1,1991) <br /> E <br /> r Tanks • 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (Zttiply Y by fee for . a5o 25o a5o Sb sa $.. jOU <br /> A each Year a kicablR). )YK <br /> 1 TANK PENALTY FEE$ ASSESSED )000( Xxl(X C., �✓fD O�.7U `moo <br /> L <br /> 1 STATE SURCHARGE + $56.00 NCH TANK (Due every 5 years) Sea California X i 5 Lode, Section 25287 <br /> T1988 through 1990 1991 through 1996 <br /> Y 0 Tanks x 556.00 <br /> (Enter migt[II and Year) 5 i <br /> c <br /> C PERMANENT CLOSURE (Remove( or Authorized Closure-in-Pl ece) TANK I.D. N(s) <br /> L N TANK(a) X 5230.00 S / <br /> 0 CLOSURE FEE • $78.00/hour.(3 hours minisaaK/TANK) .. <br /> STANK I.D. N(s) l <br /> TEMPORARY CLOSWE (Plan Rw'w i Inspections) .1 <br /> R N TANK(s) % f2 <br /> 34.00 5 1 <br /> E TEMPORARY CLOSURE FEE • $78.00/hour (3 hours minim m/TANK) G <br /> P INSTALLATION ?LAM CHECK (Plan Reviw i Construction Inspections) TANK I.D. N(a) <br /> L <br /> A n , $624.00 minims t <br /> N PLAN CHECK FEE • 578.00/hour 08 hours ainimrJ.c AC._.!•Y) <br /> RPIPAIR (Wi'ir <br /> Construction Inspections) TANK I.D. N(a) <br /> - N TANK(s) % (234.00 $G R00/hour (3 hours sJnJm tANC) $234.00 mini as t <br /> FIT8.00/hour (3 hours min./FACILITY) $234.00 minims $ <br /> IRWr'(3 hours miniWa/FACILITY) <br /> f <br /> EE • $20.00.., (pUAUTN00.1ZED RELEASE EVALUATION • 578.00/hr _ <br /> 1 <br /> S $ <br /> C CONSULTATION FEE + $78.00 <br /> /hr SAMPL-ING INSPECTION FEE • $78.00/hr <br /> 0o TOTAL OM $ <br /> C 0(o'f��4f �'./ -73 , <br /> FOR OFFICE USE ONLY - -` <br /> SLIEEP$ I COMPUTER M I.00.CODE DIST CODE AMOUNT RECEIVED CHECK Y/CASH RECEIVED SY DATE RECEIVED <br /> ;u�aar�uenaxcuaae <br /> D <br /> EH Z3 032 (REVISED 6-21-93) Page 11 <br /> ��� 71 <br />