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SAM JOAOUIN ( I JaLIC HEALTH SERVICES - ENVIRONMENTAL ) .h _IVSION <br />UAZRGROU fD STORAGE TANK PROGRAM - FEE wORKSHEE-, <br />S <br />FACILITY SITE MANE <br />CA <br />FACILITY CONTACT NAME e- <br />T <br />ry ze�c <br />SU -"A) STR0Me-Aj <br />1989 <br />1990 <br />E <br />FACILITY ADDRESS <br />SITE PHONE 0 with AREA CODE <br />L <br />"A T E1,F0,F U%/1 SaF -i <br />- - 'ItIZ O <br />.y <br />CI <br />CITY <br />STATESTATE <br />ZIP CODE <br />R of TANKS <br />/ <br />Q <br />at SITE 3 <br />VAS <br />T <br />I <br />FACILITY PENALTY FEES ASSESSED (If Appllcoble) <br />/ <br />X)Ca <br />)000( <br />P <br />APPLICANT/t ILLING MAF* <br />APPLICANT CONTACT NAME <br />V <br />%l f r; L),'- Tei c <br />L VF2M/9 <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE R WITH AREA CODE <br />N <br />-Z kAC BL�O <br />Z o9 836 Y( 20 <br />IF Tanks = 1966 1967 1986 1989 1990 <br />1991 1992 1993 1994 1995 19% <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />� � � <br />C / <br />(C loaure, irste{1atSon. -%, ) <br />TOTAL <br />N ER TkAMSFFEE a S20.DO <br />1 <br />5 <br />C I CONSULTATION FEE • S78.00/hr <br />UNAUTHORIZED RELEASE EVALUATION = 978.DO/hr <br />SAMPLING INSPECTION FEE = S78.00/hr <br />TOTAL DUE <br />"7R OFFICE USE JILT <br />f <br />S A/ <br />EH 23 032 (REVISED 3-1-93) Paae 11 <br />1966 <br />1967 <br />1966 <br />1989 <br />1990 <br />,. <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) • 2100.00 <br />.y <br />CI <br />T <br />I <br />FACILITY PENALTY FEES ASSESSED (If Appllcoble) <br />X)Ca <br />)000( <br />S <br />V <br />TANK FEE S50.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br />IF Tanks = 1966 1967 1986 1989 1990 <br />1991 1992 1993 1994 1995 19% <br />F <br />(multiply S by fee for <br />A <br />each year aMt1ceble) <br />S <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />KXxx <br />x)oa <br />S <br />L <br />I <br />STATE SURCHARGE c S56.DO eech TANK (Due every 5 years) See California <br />H L S Cade, Section 25267 <br />T <br />T <br />e Tanks_ x $56.00 <br />1986 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />_ <br />_.. <br />S <br />i <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closurrin-Place) <br />TANK I.D. RW <br />L <br />0 <br />CLOSURE FEE • 578.00/hour (3 heart ■InlaAzn/TANK) <br />/ TANK(a) x 5234.00 <br />5 <br />�( <br />U <br />TEMPORART CLOSURE (Plan Review L Inspections) <br />TANK I.D. /(a) <br />- <br />R <br />E <br />TEMFbR1lRT CLOSURE FEE = S78.00/hcur 0 ho(rt sinimm/FACILITY) <br />• 2234.DO minima <br />P <br />INSTALLATION PLAN CHECK (Plan Review L Construction Inspections) <br />TANK I.D. !(s) <br />L <br />A <br />N <br />PLAN CHECK FEE • 578.00/hour-(8 hours mininWFACILITT) <br />• t624.00 mint" <br />R <br />REPAIR FEE (workplan Review L Construction Impectlo(s) <br />TANK I.D. !(s) <br />E <br />P <br />TANK LINING REPAIR FEE a 578.00/hour (3 hours minlsWTANK) <br />t TANK(&) X 2234.00 <br />S <br />/L) fJ <br />A <br />1 <br />TANK RETROFIT REPAIR FEE • 578.00/hour 0 hours ■In./FACILITT) <br />• 5234.00 minimus <br />S <br />A <br />R <br />Al <br />PIPING REPAIR FEE • 278.00/hour (3 hours min IaLWFACILITT) <br />• S234.00 minimum <br />S <br />N <br />N ER TkAMSFFEE a S20.DO <br />1 <br />5 <br />C I CONSULTATION FEE • S78.00/hr <br />UNAUTHORIZED RELEASE EVALUATION = 978.DO/hr <br />SAMPLING INSPECTION FEE = S78.00/hr <br />TOTAL DUE <br />"7R OFFICE USE JILT <br />f <br />S A/ <br />EH 23 032 (REVISED 3-1-93) Paae 11 <br />