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-- ' r LiLL !!EALTH SERVICES - ENVIRCI 'L HEALTH DIVSION <br /> 4110 UNOEROWUND STORAGE TANK PROGRAM - FEE ...,MEET <br /> S FACILITY SITE NAME <br /> I FACILL CONTACT NAME <br /> T roV x Ii _ tt <br /> E FACILITY ADORESS <br /> SITE PHONE M with A EA CODE <br /> Z <br /> a <br /> CITY 'r 7 <br /> A STATE ZIP CODE A' of TANKS <br /> P I at SITE I <br /> P A ICANT/BILLING NAME <br /> L APP CANT CON ACT NAME <br /> T <br /> C <br /> MAILING ADDRESS <br /> If 1, APPLIC�7 It�NT PNO3 7 LN '•F//CTH AREA CODE <br /> N <br /> T Cl Y <br /> STATE ZIP CODE TYPE of APPLICATION <br /> r• (ter (Closure, Installation, etc.) <br /> s rc <br /> TOTAL <br /> A ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 1986 1987 1988 1989 1990 <br /> C 2 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> 1 %%%% %XXX 2 <br /> V TANK FEE _ 350.00/TANK (Prior to January 1,1991) <br /> E Y tanks mu5170/TANK (After January 1, 1991) <br /> = S39 19D9 iS91 j <br /> F ( ltiply a by 1990 1992 1993 1994 lee for 1086 1987 IJ 1995 1996 <br /> A each year applicable) <br /> C f <br /> 1 TANK PENALTY FEES ASSESSEDj KK%% Kxxx <br /> L 2 <br /> I STATE SURCHARGE _ (56.00 each TANK (Due evory 5 years) <br /> T See California X d S Code, Section 25287 <br /> y a tanks % $56.00 1986 through 1990 <br /> IS <br /> amount and year) 15:1 through 1996 <br /> 2 <br /> C PERMANENT CLOSURE (Removal or Authorited Closurc-in-Place) <br /> I. TANK I.D. A(a) <br /> O CLOTURE TEE _ (78.00/flour (3 hours minim"/tAIIK) <br /> 5 a 1ANC(9)_ _ % $234.00 . T <br /> UI TEMPORARY CLOSURE (Plan Review d Inspections <br /> R TANK I.D. K(s) <br /> E' TEMPORARY CLOSURE FEE = $78.00;haur (3 hours minim"/TANK) a iANK(57 K $234,00 <br /> - S <br /> P <br /> l INSTALLATION PLAN CHECK (Plan Review d Construction Imspections)I TANK I.D. a(s) <br /> A <br /> M PLAN CHECK FEE - 278.00/hour (8 hours miniman/FACILITY) _ $624.00 minimum <br /> T <br /> R[ REPAIR FEE (Workplan Review d Construction Inc <br /> E tions) TANK I.D. N(s) <br /> PI TANK LINING REPAIR FEE = 278.00/hour (3 hours ninirtnm/T•IIK) d TANK(S) % $234.00 = <br /> A ( $ <br /> I TANK RETROFIT REPAIR FEE _ (78.00/hour (3 hours min./FACILITY) $234.00 minim" <br /> R $ <br /> PIPING REPAIR FEE $78.00/hour (3 hours minim-/FACILITY) • $234.00 minimum <br /> T <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION - 278.00/lir <br /> 1 $ <br /> S <br /> C CONSULTATION FEE : $78.00/hr SAMPLING INSPECTION FEE _ 178.00/fir <br /> s <br /> Z 7 <br /> FOR OFFICE USE ONLY TOTAL DUE T <br /> ;mmr:amra!!ss!Am-�+!NFF.: s'nx!m'_r.!aR:salc .. <br /> :=_:ex!_;;:r=?!:!!s!!= J=: _ . rnmu!r.:aa*.em;en: !!:n:;oa-_ ;..;. . _ <br /> SWEEPS N COMPUTER p LOC COD _-.J_,_ -.._._ss r:.::::. :::::,,::::.__,.::..._o:_amr!n!!;.r.,:rr':mR-;.;t:;__f:=:-=::_:__:�..:�::_. '_„' .:._�_—_*t—r*.... <br /> E DIST CODE AMWNi RECEIVED CITE /CASII RECEIVED BY o.T.• <br /> D <br /> ATE RECEIVED <br /> r f a3v 3a 2 r i <br /> Bi F3 MJ I r%W�Md'naS Wi'JIIN]miri1NKSWidaiWulYmUTAti99J. uh J ..tlLLu... } m:19n:..::L <br /> ..........# :.1m Z '... L....'4u* <br /> EM 23 032 (REVISED 11-1-92) L •).e 1 w <br /> Pnge 11 �� <br />