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SAM JOAOUIN CC' Y PUBLIC HEALTH SERVICES - ENVIRQ/ENTAL 'N DIVSIOM <br /> ' ft;RC(AD STORAGE TANK PROGRAM - FEE WORK <br /> S FACILITY SITE NAME qW FACILITY CONTACT NAME <br /> t �PaF <br /> T <br /> E FACILITY ADDRESS SITE PHONE 1< with AREA CODE <br /> s <br /> 2 J c 57— <br /> CITY <br /> TC1TT STATE ZIP CODE t of TANKS <br /> A �D4 G/�. .7sZ� D at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I <br /> CMAILING ADDRESS APPLIGM PHONE M WITH AREA CODE <br /> A � 7 �� � . 5�1 � T,� .� <2�� z2z -5>zJo <br /> M <br /> STATEZIP CODE TYPE of APPLICATION <br /> T CITY (CLosure, Installation, etc.) <br /> TOTAL <br /> 1986 11987 1988 1989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXX)( I ;(X%)( f D o I (00 1017 S -;Db <br /> C )COX XX%X /U J 101 too <br /> T FACILITY PENALTY FEES ASSE ED CI A le <br /> I <br /> V TANK FEE = 550.00/TANK rio 4-ry 1 1) 5170/TANK (After January 1, 1991) <br /> E <br /> LTARKPENALTY <br /> 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F M by fee for 1 70 I' S �O <br /> A applicable) I XXXX XXXX %j o �O cj D J w r 7 0 <br /> I FEES ASSESSED I xxxx I XXXX 7 I S� Sv t 70 I t 7L U 7p I S (�D <br /> L <br /> 1 STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25287 <br /> T <br /> Y Tanks ( x 556.00 I 1988 through 1990 1991 through 1996 <br /> (Enter ;W—o t and year) p <br /> /d 5 <br /> C PERMANENT CLOSU0.E (Removal or Authorized Closure-in-Place) I TANK LD. t(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minirmm/TANK) I M TANK(s)�_ % 5234.00 Jed S <br /> 5 <br /> U TEMPORARY CLOSURE (Plan Review 3 Inspections) TANK LD, d(s) <br /> R <br /> El TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimAn/TANK) I N TANK(s)_ X 5234.00 = S <br /> PI INSTALLATION PLAN CHECK (Plan Review 3 Construction Inspections)I TANK 1_0. #(s) <br /> L <br /> A S <br /> MPLAM CHECK FEE = 578.00/hour (8 hours viniaL m/FACILITY) = 5624.00 minimm <br /> R I REPAIR FEE (Workplan Review 3 C0n5trULtion Inspections) TANK I.D. f(s) <br /> E <br /> P TANK LINING REPAIR FEE = 278.00/hour (3 hours minimim/TANK) k TANK(s) X 5234.00 = 5 <br /> A 5 <br /> I TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours .min./FACILITY) = $234.00 minin <br /> R <br /> PIPING REPAIR EEE = 578.00/hour (3 hours minimm/FACILITY) = 5234.00 minima 5 <br /> M TRANSFER FEE = 520.00 I I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> I <br /> Cl CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL OLE S <br /> FOR OFFICE USE ONLY <br /> SEEPS N COMPUTER t LOC CODE DIST CODE AMOUNT .RECEIVED CHECK ;0/CASH RECEIVED 3Y DATE RECEIVED <br /> S <br /> EH 23 032 (REVISED 6-21-93) Page 11 / <br /> l �� <br />