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UMCIAL <br /> SAM JOADUTN COUNTY PUBLICOEALTHTANK PREOGRAME FEE UORKSHEET HEALTH DIVSION <br /> XVIR <br /> UNDERCRQJIm <br /> FACILITY CONTACT NAME <br /> SI FACILITY SITE NAME <br /> C, SITE PHONE # with AREA COOP <br /> i <br /> E FACILITY ADDRESS / f• + <br /> # of TANKS <br /> R (I STATE ZIP CODE at SITE <br /> CITY <br /> A ,. � /) iF\ T�+ �lV Ci�.1 � 17 <br /> iI APPLICANT CONTACT NAME <br /> P <br /> p APPLICANT/BILLING NAME <br /> L I APPLICANT PHONE # WITH AREA CODE <br /> I <br /> C NAILING ADDRESS <br /> AP APPLICATION <br /> N STATE ZIP CODE TYLoewe, Installation, etc.) D <br /> T CITY (� <br /> T07AL 7"2�0 <br /> 1986 1987 11968 1198 11990 no <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 3100.00 XXXX XXXX ( /1 s 3�G) <br /> A XXXX XXX% //7�l ;f, 1 /' 1 S <br /> C <br /> I I <br /> T FACILITY PENALTY FEES ASSESSED (If Applicab e) 5170/TANK (After January 1. 1991) <br /> V TANK FEE = 350.00/TANK CPrior to January 1,1991) <br /> E 1986 11987 11988 1999 11990 1991 1992 1993 1994 1995 1996 C�D <br /> % Tanks = <br /> FI (multip y % by fee for XXXX XXXX n ,7�' �L•' -� �I <br /> A each year applicable) <br /> 11 TANK PENALTY FEES ASSESSED I XXXX XXXX <br /> L <br /> [ STATE SURCHARGE 356.00 each TANK (Due every 5 years) See California H 3 S Code, Section 2528 <br /> 991 through 1996 <br /> T 1988 through 1990 qq <br /> Y� % Tanks x 556.00 <br /> (Enter amount and Year) <br /> TANK (•D• #(s) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) <br /> L K 3234.00 S � AL, <br /> # TANK(5) I <br /> 0 CLOSURE FEE = 378.00/hour (3 hours minimm/TANKO <br /> S TANK I.D. #(s) - <br /> U TEMPORARY CLOSURE (Plan Review 3 lrupectior>s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 378.00/hour (3 hours minimwyFACILITY) 1234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review i Construction lnspections)I TANK t.O• #(s) <br /> L <br /> A = S624.00 minimum S <br /> N PLAN CHECK FEE = 378.00/hour (8 hours minimm/FACILITY) <br /> R REPAIR FEE (Workplan Review & Construction [ruapedtions) <br /> TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 378.00/hour (3 hours minimum/TANK) # TANK(s) X 3234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE - S78.00/hour (3 hours min./FACILITY) = 3234.00 minimum 3 <br /> R = S234.00 minimum S <br /> PIPING REPAIR FEE = 378.00/hour (3 hours minimum/FACILITY) <br /> N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 378.00/hr <br /> 3 <br /> I <br /> S $ <br /> C CONSULTATION FEE = 378.00/hr I SAMPLING INSPECTION FEE = 378.00/hr <br /> 7 .. TOTAL DUE <br /> O\� E AMOUNT 2EC ` I v rJ'rr �y� — <br /> FOR OFFICE USE ONLT <br /> SUEEPS # COMPUTER t LOC CODE DIS <br /> LVED ' CHECX #/CASH I RECEIVED SY I DATE RECEIVED <br /> Page 11 J <br /> l (�., 1� 1'J J f <br /> Ex 23 032 (REVISED i0-28-93) �� (�� / �'+ <br />