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NO.0-8 EP05 <br /> SAM JaU)UIM C01Mn dLIC HEALTH SERVICES - ENVIRON)WAL HEALTH 01 JM <br /> LWUGWM STORArE TAMC PR=AM - FEE HORISHM <br /> FACILITY CONTACT NAME <br /> S, FACILITY SITE NAME <br /> T <br /> E, FACILITY ADDRESS SITE PHONE a with AREA CME <br /> s' <br /> � C..Y `' ! STA.2;Z ;P CSE it of TANKS <br /> A �:rC,,rr��� '�� 1 -l��rcY� I� at SITE <br /> P <br /> P APPL;C.INT/�.ILLING NAME APPLJ i C7NTAC' NAME <br /> L1 `J o�-r Cc-r,�0, rrt rrz <br /> Ci HAILING ADDRESS <br /> APO'-:CANT PHONE M w1TM AREA CSE <br /> N TYPE of APPLICATION \(A.tl [- <br /> C17Y STATE; ZIP =E <br /> i (Closure, Instailation, err.) v i <br /> 1 ti�,r u SrI <br /> TOTAL <br /> 1986 1987 119W 11989 I 1,990 <br /> ANNUAL FAC;LITY FEE (Prior t0 January 1, 1991) - $100.00 <br /> { Ai XXXX xxxx I X)= ' xxxX ! Xxxx S x)O(X)o(xxxl0o0( <br /> C1 <br /> T FACILITY PENALTY FESS ASSESSED (If Applicab(e) i XXXX XXXX Xxxx ` XXXX XXXX $ XXXXXXXXx)000( <br /> I <br /> Y TANK FEE = S50.00/TANK (Prior to January 1,1991) S17DITANK (After January 1, 1991) <br /> E <br /> 0 Tanks = 1986 1 1987 ; 1988 1959 4 1990 1491 1992 11993 1994 1995 1996 <br /> F (multiply a by fee for <br /> A earn year aoplirab(e) XXXX XXXX I )Dqo( + XXXX XXXX I 1 I S <br /> I IANC PENALTY FEES ASSESSED I XXXX I X)xx k XXXX I KXXX I XXX): <br /> I 1 I <br /> L <br /> I STATE SURCHARGE ■ 556.00 each TANK (Due every 5 years) Set California H 3 S Code, Section 25287 <br /> T199, through 1996 <br /> Y 0 Tanks x $56.131) 1448 through 1490 <br /> (Enter =wunt and ytar) S <br /> C PERMANENT CLDSilRE (Retsv-r:l or Authorized Closure-in-Piace) TANK I.D. M(s) <br /> LwNTANK) I R TANKS) X SZ34.00 = S <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minim <br /> S TANK (.'D. #(S) <br /> U TEMPORARY CLOSURE (Plan Review L ItapetTi0m) <br /> R S <br /> S23G.D0 minim <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours mininuNFACILITY) us <br /> Pi INSTALLATION PLAN CHECK (Plan Review L Construction Inspecti;ons)I TANK I.O. 9(s) <br /> L <br /> A <br /> R PLAN CHECK FEE ■ 573.00/hour (5 hours mininnIFACILITY) = 5624.00 minimus S <br /> R REPAIR FEE (workplan Review Z Construction In3pectia4) I TANK I.D. «(s) <br /> E it TANK(s) X 5234.00 = S <br /> P TANK LINING REPAIR FEE ■ S75.D0/hour (3 hours rainiaYN TANK) <br /> A <br /> I TANK RETROFIT REPAIR FEE ■ 578.00/hour (3 hours min./FACILITY) = $Z34.00 minimum t <br /> R <br /> PIPING REPAIR FEE = S75.00/hour (3 hours minimam/FACILITY) S234.00 minimum S <br /> M <br /> TRANSFER FEE a 520-00 I I UNAUTHORIZED RELEASE EVALUATION - S78.00/hr <br /> I i I <br /> S <br /> C CONSULTATION FEE = 875.00/hr SAMPLING INSPECTION FEE = 578.00/hr I S <br /> TOTAL M* S <br /> FOR OFFICE USE ONLY <br /> SYEEPS >Y COl(PUTER M LOC CODE DIST f AMOUNT RECEIVED 1 CHECK M/CASH RECEIVED Br D7!-! <br /> SVED <br /> a; <br /> a � <br />