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SAM JOADUIM =]WIT PUBLIC HEALTH SERVICES - ENVIRONMENTAL NEAL,M DIVSIOM <br />UNDERGROLND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAME <br />- <br />FACILITY CONTACT NAME <br />S TRO M ex) <br />T <br />C.9 n 0"- T,,.+c V1 <br />SUSAN <br />E <br />FACILITY ADDRESS <br />SITE PNONE a with AREA CODE <br />i E[EtIcNT// Saflx <br />fjr,45 <br />C <br />T <br />FACILITY PENAL" FEES ASSESSED (If Applicable) <br />X%%X <br />A <br />CITY "� <br />T,i?AcC4 <br />STATE <br />L-A <br />ZIP CODE <br />a of TANKS <br />at SITE 3 <br />1 <br />V <br />TANK FEE • 550.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />P <br />PADPL <br />ICANT/BILLING HAKE <br />APPLICANT CONTACT MAKE <br />1987 1988 <br />�t car 0,�:/`29C <br />L VF2Mft <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE R WITH AREA CODE <br />M <br />_z LZACIX &JIQ <br />Z09- UO3E- VI ZO <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />.� <br />(Closure, +rvt*ua 'l w; --z' I <br />TOTAL <br />A <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) • $100.00 <br />1966 <br />1987 <br />1 1988 <br />1989 1990 <br />J.1 <br />= QEtiVC <br />C <br />T <br />FACILITY PENAL" FEES ASSESSED (If Applicable) <br />X%%X <br />XXX)! <br />S <br />1 <br />V <br />TANK FEE • 550.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br />F <br />A <br />I Tanks • <br />(multiply s by fee for <br />each year applicable) <br />1986 <br />1987 1988 <br />1989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />5 <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XX%% <br />L <br />I <br />STATE SURCHARGE •: S56.00 each TANK (Due every 5 years) See CaLifornla H L S Code, Section 25287 <br />T <br />R Tanks z S56.00 <br />(Enter amort and year) <br />1986 through 1990 <br />1991 through 1996 <br />M4 Is <br />G <br />C <br />L <br />PERMANENT CLOSURE (Removal or Authorized Closure -In -Placa) <br />TANK I.D. #(a) <br />0 <br />CLOSURE FEE • S78.00/hour (3 hours minimWTANK) <br />M TAMK(s) % 5234.00 • <br />S <br />/ D C <br />S <br />U <br />R <br />TEMPORARY CLOSURE (Plan Review L Inspection$) <br />TANK I.D. /(a) <br />- <br />E <br />TEMPORARY CLOSTRE FEE • 578.00/hour (3 hors Minimus/FACILITY) <br />• 5234.00 minimum <br />S <br />� <br />P <br />L <br />INSTALLATION PLAN CHECK (Plan Review L Construction Inspections) <br />TANK I.D. #(a) <br />N <br />AN.4 <br />PLAN CHECK FEE • S78.00/hour (b Nouns wlnleuNFACILITT) <br />5626.00 mini mum <br />S <br />R <br />E <br />REPAIR FEE (Workplan Review L Construction Inapections) <br />TANK I.D. S(a) <br />•P <br />A <br />TANK LINING REPAIR FEE a $78.00/hour (3 hours minisua/TANK) <br />R TANK(s) % 5234.00 + <br />S <br />I <br />R <br />TANK RETROFIT REPAIR FEE a 578.00/hour (3 hors win./FACILITY) <br />• 5234.00 minima <br />i <br />N 4 <br />PIPING REPAIR FEE + %78.00/hour (3 hours mininsat FACILITY) <br />a 5234.00 miniww <br />f <br />N <br />M TRANSFER FEE • 520.00 LNALITHCRIZED RELEASE EVALUATION + 578.D0/hr i N <br />I <br />5 <br />C CONSULTATION FEE + 578.00/hr I SAMPLING INSPECTION FEE • %78.00/hr 5 <br />TOTAL DUE I % <br />FOR OFFICE USE ONLY <br />EN 23 032 (REVISED 3-1-931 Pace 11 <br />