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SAH �....--. I 1 -"CL "!RIC HEALTH SERVICES - ENVIRONMENTAL HE*OlvBION <br /> ONDMI �/ � n <br /> IM AGE TANK PROGRAM - FEE WORKSHEET 'V <br /> S FACILI Y SITE NAME FACILITY CONTACT NVE <br /> I V <br /> T <br /> E FACT L�T�DIRE S SITB PNON # with AREA C66E _ <br /> CITY C STATE ZIP CODE # of TANKS nn^,�,�e1I <br /> A (] 15;2z) at SITE .9- !la "' <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N ` D <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> 6 (Closure, Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1986 1987 1988 1989 1990 <br /> A /UO 700nsm <br /> c T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx %V(� (�I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 8170/TANK (After January 1, 1991) <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee forC each year applicable) �(� 0160 p 3Iy�0I TANK PENALTY FEES ASSESSED xxxx xxxx �(j(� � 0� 3yo 3(�L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See CaliforniarH & S Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> // $ 9% r <br /> CPERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) x $234.00 = $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TIANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum 5 <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum 5 <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr $ <br /> N1 <br /> S <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = 578.00/hr 5 <br /> fillTOTAL DUE S <br /> FOR OFFICE <br /> USE ONLY ,'/A s <br /> �! <br /> ...................._.................................... ...:..:. ................ ..H. <br /> ......_....._ !%�' Jj_ /f _.......:F.:...__............................................__.......:G'......._.._ .....n.. <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> 5 <br /> ._.............::...... :.:-:_ , ...._...— ::::..._...._,.........,.... .:,-, ...,,.._...,.._T...,...._.......,. <br /> ._...................:.......::...._..:............._................::.:.::::...::::::::::::.........-.............. ......... ;_......:.._..........:.:::.... ......__...__...........:...:.. '- <br /> _!::::::::!!!!!::,! <br /> EH 23 032 (REVISED 11-1-92) • Page 11 • <br />