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SAN 10,ft IN (XfYTv pON.IC HEALTH SMICES - ENVIRONMENTAL NEW a u,raga . <br /> UND 'ORD STORAGE TANK PROMAN - FEE {ARK' -T <br /> S FACILITY SITE NAME FACILITY TACT NAME <br /> I Truk rnrnJ <br /> T <br /> E FACILITY ADDRESS SITE PRONE # with AREA CODE <br /> L <br /> zit wtsr Ec�ur�rrl _Sra _E_r zo9. 5sss o <br /> CITY STATE ZIP LODE # of TANKS <br /> A r-P2A C CA ji M 6 at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> � <br /> rNG GLT F T2Ac . PAu (�ci2N1A9 <br /> C HAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A SZo 7-RAC, /3L (/n, Zv9- &36— eplZo <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> 7^kA C _ CA C�S37 (Closure, iwseakkatien cJ <br /> 1 TOTAL <br /> 1986 1987 1988 1989 1990 Ary E/! <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A 5 RG(LdtS <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) X)OCX )000( S <br /> 1 <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 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A <br /> each year applicable) 5 <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XX)IX S <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H E S Code, Section 25287 <br /> T <br /> T # Tanks_f x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> Al A 4 �� 5 SK qEl PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3'hours minimum/TANK) # TANK(s)___ X 5234.00 = % 3LI, O <br /> S <br /> U TEMPORARY CLOSURE (Plan Review i Inspections) TANK I.D. #(s) <br /> - <br /> R <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minim nVTANK) # PANK(s)_ X SZ34.00 �-- <br /> 1 <br /> I P INSTALLATION PLAN CHECK (Plan Review i Cc sstruction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> H PLAN CHECK FEE = 578.00/hour (8 hours minim mVFACILITY) 5624.00 minimum 5 -8— <br /> i <br /> R REPAIR FEE (Workplan Review i Construction Inspections) TANK I.D. #(s) <br /> E <br /> j P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) # TANK(s) X 5234.00 = 5 <br /> I 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 /> H TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 278.00/hr 5 ,� <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr 5 <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> SWEEPS # I COMPUTER # I LOC CODE I DIST CODE I AMOUNT RECEIVED CHECK #/CASH I RECEIVED BY I DATE RECEIVED <br /> = S <br /> EN 23 032 (REVISED 11-1-92) Page 11 <br />