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SAN jmwiR cDUjdb4JBLIC HEALTH SERVICES - ENVIRONMENTAL HEA&IVSION <br /> � fLNOINkm STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ' FACILITY CONTACT NAME <br /> S FACILITY•SITE NAME? <br /> I 'X0 4-0'- 8j IR.de 5 <br /> T SITE PHONE # with AREA CODE <br /> E FACILITY ADDRESS <br /> / S/ c/ �, S c v� <br /> & STATE 21P CODE # of TANKS <br /> CITY �S Z cJ / at SITE o2 <br /> A <br /> P ,S�-t7 C n APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L Ph ; '�A � 5 <br /> I APPLICANT PHONE # WITH AREA CODE _ <br /> C MAILING ADDRESS <br /> A P, p /3ox 73YS s <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITY (K�S ORt 9 Y/ (Closure, Installat on, etc.) <br /> OJYOJ F TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 /O✓0 /C1C7. $ Sock <br /> A <br /> C XXXX XXXX BOO voo /0 $ 3O0 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> 1 $170/TANK (After January 1, 1991) <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) <br /> E �_. 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> # Tanks = _ 2 <br /> F (multiply # by fee for <br /> A each year applicable) /U'O /00 /00 /UO /00 3y0 D 3 O <br /> CV <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX /C70 C[0O <br /> L <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California X & S Code, Section 25287 <br /> T 1986 through 1990 1991 through 1996 <br /> Y # Tanks_ x 556.00 <br /> (Enter amount and year) `�v CPAid w% c/o 5a P/Gti, S /� a <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> L # TANK(s)_ X $234.00 = $ <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /> STANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review & inspections) <br /> R $ <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimun/TANK) # TANK(s)_ X $234.00 = <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction inspections) TANK I.D. #(s) <br /> L <br /> A = $624.00 minimum $ <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = <br /> A $ <br /> 1 TANK RETROFIT REPAIR FEE = 878.00/hour (3 hours min./FACILITY) = $234.00 minimum <br /> N m/ = $234.00 minimum S <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimFACILITY) <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = E78.00/hr <br /> S <br /> 1 <br /> S = 578.00/hr $ <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE $ 3 7v1 O <br /> Y _!!!!!!i: :!! <br /> ONLY <br /> -..._...........__..._........__...... <br /> USE _._. .......:......._,_.�.._-::::::,_.—.....::.........._......._............................,......... <br /> FOR Of ..................__ ......._............... ...........:,.......:..,................:.....:............................. <br /> .................._............................::... ......::-:::............:::::-:::::::,::::�::,:_.......................:::::::::::::::::::::::::::::::::c-�::::::::::::::::::::::!!-_-!!E!.;':-"$iiiiii!!iiid isiiiiii_;;;iiiiiiii`r;iii_:s!!!!!ii!!!!w`�::�:,:::: ATE RECE_:�:::::::::::� <br /> ::::::::...............:........:...................................................._.............. <br /> ...................::::.::::_: ::::::�::..::::�::.........:.:-_:::-...::::.:..:::_::_-::::.:!!!i;:::::;i::::r:!.!ii!!;i;�!!i!;s!ii:e;!:::::::::::::::_::::::::::::_:�:�:__:::::::::::�:::::...::___..::_::..::: RECEIVED <br /> _.... <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY D <br /> v7oRis 33 S <br /> :: d-� ......._........................__....__.....__.....-- -............._:_..........._....... :::.:::::::_: <br /> ii !i:i:—._:=ie:::i:::iiie=::�:e_—vGi.. <br /> ii!!!!!:cc=c:::___:c'_._:::::c:u:::... <br /> Z7 -,4- V� Z <br /> EH 23 032 (REVISED 11-1.92) ,�:L `'! 7 ' ' 1� " "• 11 �� <br />