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SAM JQA9UIN COUNT LIC HEALTH SERVICES - ENVIRONMENTAL 1VSI0N <br /> UMEOW STORAGE TANK PROGRA1i - FEE WORKSHEET <br /> .: NAME K61 br 6 r FACILITY CONTACT NAME <br /> .Y ADDRESS SITE PHONE 0 with AREA CODE <br /> L C Ca <br /> .ITT STAT P CODE N of TANKS <br /> P <br /> CSC._. f�►r1 r, �, () ' at SITE �. <br /> P APPLICANT/BILLING NA��I�.—_�f'�l APPLICANT CONTACT NAME <br /> 1 <br /> C MAILIN3 ADDRESS f .' APPLICANT PHONE N WITH AREA COUP <br /> M <br /> T <br /> f <br /> I STATE ZIP CODE TYPE of APPLICATION <br /> OK __ ( Ir- (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1940 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 <br /> cxxxx xxxx ��� / s o <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) xxxx xxxx <br /> I ! /00,00 <br /> V TANK FEE _ %50-00/TANK (Prior to January 1,1991) 1170/TANK (After January 1, 1991) <br /> E <br /> R Tanks ;t 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (r+ultiply N by fee for <br /> A each year applicable) xxxx xxxx 1(x ' '� ! <br /> C 100, 0o <br /> 1 TANK PENALTY FEES ASSESSED xxxx xxxx Icx s ' (1U„p o <br /> L <br /> I RTATE RURCHARCII = OS6.00 each TANK (Due every 5 years) tee California H It S Cade, location 25287 <br /> T <br /> Y 0 TanksY s x 156.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> C VERNANE1fT CLO9l1R1_ (Rewoval or Authorized Closure-ln-Place) 1ANK I.D. A(a) <br /> L <br /> 0 CLOSURE FEE _ 978.00/hour (3 hours minimum/TANK) §k TANK(&) x !234.00 ! <br /> s <br /> U TEMPORARY CLOSURE (Plan Review ! Inspections) TANK I.D. !(a) <br /> R <br /> F ITW*k1l c.1115 W1 FET: = i}ill,ll(llha w 0 %%W% 1«ini1�1f1►f�K1IK.1 iANW,(4) X MUM • <br /> P INSTALLATION PLAN CHECK (Plan Review i Construction Inspections) TANK I.D. Ae(s) <br /> L <br /> A <br /> N PLAN CHECK FEE * !78.00/hour (8 hours minimum/FACILITY) !624.00 minimum �.• <br /> R REPAIR FEE (Workplan Review b Construction Inspections) TANK I.D. #(a) <br /> E <br /> P TANK LINING REPAIR FEE - 578.00/hour (3 hours minimum/TANK) R TANK(&) x !234.00 = S <br /> A <br /> 1 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) * 9234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hour* minimum/FACILITY) _ 9234.00 minimum <br /> H TRANSFER FEE _ !20.00 UNAUTHORIZED RELEASE EVALUATION ■ $78.00/hr ; <br /> 1 <br /> S <br /> C CONSULTATION FEE 578.00/hr SAMPLING INSPECTION FEE _ 178.00/hr i <br /> TOTAL DILE ! 0 V <br /> FOR OFFICE USE ONLT <br /> !- §!nRa?§rnm!nrnmRmmlm!ni Rmmnrmml�llnmrmnmsnsa§InRnm!nr�mrunnn m!r!1nu§§unmmrrl�mmmnnrtmuu!mRRm m�mF3mR!gqmnr mm��§R§ m <br /> --°i °i f*fWf++!{an.i!!gqq?qr.?rrgrr?r§ea?4311??i!!!g19!P?II11+9!!i!'.iI!?§?§r§?43§??!4!li!Illi.n.ll!!.!iII!IIIIir!i!!miI!!!E!!E!!!.!{lIII!II!III!I!!il!I!iilli!!Ilm!1!{?!§llFlrl#§§???§+44!!!I!!!!N9'!il!!iil i+!Ir IR§99i�mn+n++rynr(!m§g�!r e f r r r n r r::r: •4 ' <br /> nH SWEEPS R COMPUTER !MLOC CODE DIST CODE AMOUNT RECEIVED CHECK N/CASH RECEIVED BY DATE RECEIVED <br /> § <br /> +r <br /> ram <br /> 1!°!R!?[.._uRlniR!.i....E.........1.1�lRlRR§1Rn§3lmnlllll�l nnFl{mR!FF!!R4!§3mi11 IIIR§i i l��l�rnrr!f!§!!!3!§InlnminumnnlnrrrrEl§slE§n13im!!nmm�nnnmm�unnr!r§trrriR§S§ <br /> ;:fir?.?r??. ,,:{gn!i§.::;::pp::;r;t:v:ui:as:crrs•Ie a esu ua a wnn: err: a rrss;ra e e a r-{{+. ... . .. Rl IIIrtInnilNlmmnnlllllRlRm!F§'.!1!gllnlll IlmRmrm!m1imRlRl <br /> EH 23 032 (REVISED 6-21-43) � page 11 <br />