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SUI JOAOIJIV 'XTY PUBLIC HEALTH SERVICES - ERVIR0101ENTA, LIN DIVSION <br /> )ERGR1lp STORAGE TANK PROGRAM - FEE WORK! _ <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AR CCOE <br /> CITY / �/ IT E ZIP CODE # of TAN <br /> P /� at SITE <br /> /kATL P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> moo- I v/, G Grivo <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A Zo w. 76 <br /> T j CITY STAT ZIP CODE TYPE of APPLICATION <br /> /N C N POG/ � sscl 1. (Closure, InstalUation, etc.) <br /> SZ 89 1990 TOTAL <br /> 1986 1987 1988 19 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> � X%Y)( 70(XX XXXX $ Zun <br /> i FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX J[X%X (DO fop S Zop <br /> 1 <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply fee for <br /> A each year app icable) XXXX %JOLT XXXX n <br /> C S s� f 7� r 99 r 99 r 99 $ 7�jD <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX I XXXX Sv $O / 7p r7p 7U r�� $ <br /> 1 STATE SURCHARGE - S56.00 each TANK (Due every 5 years) See California H g S Code, Section 25287 <br /> T <br /> 7 # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 278.00/hour (3 hours minimLAVTANK) # TANK(s) <br /> S _ % $234.00 = 3 <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours mininun/FACILITY) $234.00 mini mm S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> LlA <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minium/FACILITY) _ $624.00 minimum $ <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.001hour (3 tours minimm/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> ( TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) 5234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = $78.00/hour (3 hours minimm/FACILITY) = SZ34.00 minimum S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED IZED RELEASE EVALUATION = 578.00/hr S <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLIRG INSPECTION FEE = $78.00/hr $ <br /> TOTAL DUE S 1 ,160 <br /> mfQR 'PLA <br /> LMANCI <br /> a SWEEPS 3�'�"CbMPCI'TER a�tiC'CbDE�'"6T"sT�Ts otirit^kE2ET�"p��CH�CR'-dJ"CASI✓��RECE7�E6-8i'�"-tiAYE-aE['E]vEls—` <br /> n <br /> -r. <br /> E4 23 032 (REVISED 4-29-94) Page 11 <br /> ���Z� � 0� (n- 5�{ ( !%AkJ-� ��[� 013 <br />