Laserfiche WebLink
SAM "WIN MXT PUBLIC HEALTH SERVICES - ENVIRONMENTAL 11WO DIVSION <br /> STORAGE TAK PROGRAM - FEE WORKSHEE <br /> SJT <br /> T <br /> ITYE NAME FACILITY CONTACT NAME <br /> E FACILADDRESS �yVWil <br /> 0r with AREA CODE <br /> CITY /�/[ `f ��' �f TANKR <br /> P 04 SITE <br /> P APPLICANT BILLING NAME Y19 �` NITACT H <br /> C MAILING ADDRESS ONE # WITH AREA CE <br /> Aa• �-'� - --X75/9° <br /> N <br /> T CiTY // ST TE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) . $100.00 <br /> A fva /ate /aa /� /Ott s Jrp Z? <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx �p,rj /py,O /Ap S 500 (/ <br /> 1 <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (muttipty # by fee for �h <br /> A each year applicable) 6;7 ,;C 56 /70 <br /> C <br /> I TANK PENALTY FEES ASSESSED XXX)( XXXX 450 L50 5V /?D 17a S <br /> L V <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See Callfornis H & S Code, Section 25287 <br /> T <br /> Y # Tanks _ x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-PLace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) x $234.00 = S <br /> 5 <br /> U TEMPORARY CLOSURE (Plan Review S Inspections) TANK I.D. #(s) <br /> R <br /> [TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 S <br /> P INSTALLATION PLAN CHECK (Plan Review b 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 5 <br /> R REPAIR FEE (Workplan Review 9 Construction Inspections) TANK 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 = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PiPING REPAIR FEE 578.00/hour (3 hours minimum/FACILiTY) 5234.00 minimum S <br /> M TRANSFER FEE = $20,00 UNAUTHORIZED RELEASE EVALUATION ■ $78.00/hr S <br /> 1 <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr S <br /> TOTAL Ol1E S Cl�. <br /> FOR OFFICE LME ONLY <br /> AlkiiHm!!lHHII{!iiliiilHl!$nifinm!!i!m!G!!H9lla.. . ?:.::' •i:,.,;iiF.iFs"::!!:iszeaiii!i.".:'i:AEmn�m!m!!tt!!1tH r !f'i°!!1!!!7mif?mPr.? f..mr9ili.i!'s£33e?3??€f:?!'AFEr±i>!i'l�.=s!!?3!m!nm!!mi:Htln <br /> i',' mtfr.!�rmlnmrin!rmHnlmm!lmw�u�m:�mLn�.;.-�-tn1...m <br /> ..: ......:....: ....cud:iiu�ihirf$i!$$Hiirir !1!lSi1Hi!i$$s!t!iHli!!�S!!iriiu'vHHm18I8HHi!H1Hluiilil'd9iuHH!litie'sniff$HmliilitirNHiH$Hien!!!i!!$3$srlllxH.HHm!!!i!i!'siiielilFeiill:rllGiiilliHiiHiF'!HH$mNiHiiHmlBiHiiti$liiim{ielii!!ii$illi:i$iHiei:�s3i:.8fiilN <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> x <br /> '''' #' T ss""'r':E'i-F+;i{linF.!HH'rr iinllliEiHHiiHF.F!?:Ef?. r!5!!9!fPi!ll:fli.9iSi$?!!3'i!.a H!!lli:T;!!H"nmiHiiii iilFllkHFSHIH ?:.:.*T• }!@smi!m!I a _T,mTitmmm!43ii7iHiHnm r mml!mHH.1 1fl3l.:.i£:37mnm'u!P.�-H?T.'jf...1 <br /> ':, .....s:si...m„r,.:lY:lssss:es:$i:ltir7n-miiHiiHiiilili!liHiliiilii:imiilli;.11inu:liielH�F.H.slilHlia au$iiiHlluiiilHii:fiiiiHmdmHi?14Hi!!'i�m>�•.nimHLlH}sSr.---,„„r�nf}uhiuHr;ifHmmmiliiilliilill+iF!!iimiA!IL'!IIHHi.II°HHHHmtfim•!leliFiir3;:mliuil!H;iivaiiiu]ui!il <br /> S <br /> EH 23 032 (REVISED 11-1-42) � page 11 —R V t � > <br />