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SAM JOADUIN BURT PUBLIC HEALTH SERVICES - ENVIRONMENTAL P"'.TH DIVSION <br /> 9tG2a= STORMS TANK PROGRAM - FIE NORKSHE <br /> ' FACILITY SITE NAME FACILITY CONTACT NAME <br /> T <br /> E FACILITY AODRE55 SITE PHONE # with AREA CODE <br /> 8 <br /> CITY ST E ZIP CODE # of TANKS <br /> A GC4/ -Fje-14 at SITE <br /> /�fAfv P APPLICANT/BILLING NAME !'^T APPLICANT CONTACT NAME <br /> 4.C— <br /> MAILING <br /> G LY✓V <br /> C MAILING ADDRESS APPLICANT PHONE # VITH AREA CODE <br /> N <br /> Z o w. 76 to ST <br /> T CITY J _,l STAT ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> - SZ TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 XXO Z <br /> A XXX( X)00( )0= 'r`y"+S /,PC;, S uo <br /> C <br /> T FACILI77 PENALTY FEES ASSESSED (If Applicable) XXXX 70(X)( xaxx fop S LDp ✓ 177OZ <br /> V TANK FEE = 550.00/TANK (Prior to Japery 1,1991) S1 /TANK After January 1, 1991) <br /> E <br /> Al Tanks1986 1987 11988 1989 1 kO9O 19V 199 1 1994 1 1995 1996 <br /> F (multiply fee for cc pp <br /> A each year app icabla) )OM XXXX ( X7(70( sa (7D t7D ASD t70 S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX X7000XFY Sv /7D i7U i 9J A7� S f LAG <br /> L / <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California X & S Code, Section 25287 <br /> T <br /> Y # Tanks z $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Resoval or Authorized Closure-in-P(ace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours miniau/TANK) At TANK(s)_ X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hags minimm/FACILIT7) 2234.00 mini mm S <br /> ?I INSTALLATION PUN CHECK (Plan Review & Construction Inspections) TANK S.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 578.001hour (8 hours minimum/FACILITY) = 2624.00 minimum 2 <br /> R REPAIR FEE (workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 278.00/hour (3 hours rinimm/FACILIT7) = $234.00 mini mum 5 <br /> M TRANSFER FEE = $20.00HORIZED RELEASE EVALUATION = 578.00/hr <br /> UNAUTS <br /> t <br /> S <br /> ClCONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE 11 _QMI.7 - <br /> SLOC_ GIST COOE NOUN LHEC'�CICAs REtEIVEb 8Y�6AiE-tEtEtVtD p <br /> EH 23 032 (REVISED 4-29-94) Page 11 <br />