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r <br /> n r� <br /> Is . 212 <br /> �',t.N <br /> ���,„ �, i(,i't^l ���l�:�. (IID!V1510N <br /> SAM Jd1 tN NVVIRO M NTALTY LHHEALTH DI VISIONLIC HEALTH VICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE 1KIRKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT MA <br /> A 5 T�,. s i es4 us ernb/� /-.<-C> <br /> I FAC)g7T ADDRESS t- _ S TE P ! w th AREA CODE <br /> L .7 .S [. , vcpQiS� ASO <br /> T CITYof <br /> Y ((�� (OTe/IG SATE 2 7/_ at SITENKS <br /> AAPPLICANT/8ILLING NAME APPLI T CONTACT NAME <br /> P eo , N�L.� rndo�� <br /> LH AR <br /> 1 NAILING ADDRESS � �. <br /> 2103 �. B) L mow r� <br /> T CITY %2�jNa S�)E 21�COp,7of CLARESTALLADTNidI, ate. K�!'T'IO+ L- <br /> alF ��j S* <br /> TOTAL <br /> A 1986 198) .1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) a $100.00 S <br /> E TANK FEE S50.00/TANK (prior to January 1,1991) S17OfTAHK (after January 1, 1991) <br /> F s Tanks 1 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (nul[iply T�v fee for S <br /> C each year applicable) <br /> L STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See Ceti fornix N t S Code, Section 25287 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter WO.Mt aril year) 5 <br /> PERMANENT CLOSURti (RE�DViI�Dr AuthDFl xed 1:1b�1�+1F1=Plate) TANK I.D. !(t) <br /> I <br /> l CLOSURE FEE a -553.00;per hour. (3 Moura MIhIm(im par TANK) 9 TANK(s)_ X $159.00 • 5 <br /> 0 — <br /> S <br /> TEMPORARY CLOSUREL(A ort -tisle Permit, for reV16M/inapettiona) TANK I.O. f(s) <br /> E TEMPORARY CLOSURE TEE = $150.00 each TANK R TANK(a) _ X 5150.00 = S <br /> P PLAN CHECK (Install. Plan Review t Construction inspections) TANK t.D. #(s) <br /> L <br /> N PUN CHECK FEE - $53.00 per hour (8 hours minim per Facility) = $424.00 minimum 5 <br /> R REPAIR FEE (workplan review i construction irspectiens) TALK I.D. !(s) <br /> P TANK REPAIR FEE - 553.00 per hour (3 hours minlmm/TAHK) k TANK(s) I X $159.00 S <br /> A <br /> I n <br /> R PIPING REPAIR FEE - 253.00 per hour (3 hour mint” per facility 5159.00) <br /> M TRANSFER FEE - S20.00 UNAUTHORIZED RELEASE EVALUATION - S53.00/hr S <br /> I <br /> S1 <br /> CONSULTATION FEE - S53.00/hr SAMPLING INSPECTION FEE - S53.00/hr <br /> TOTAL DUE 5 0" <br /> E--2UE L EC ECE SED"`BY - 6AT ECETVE6— <br /> 5 T e <br /> EH 23 032 (Revised 4/8/91) Page 11 <br />