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--_ "MENVIRONMENTALIEALTM'O IVIS ION..... T <br /> UNDER WND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTA E <br /> F <br /> A i t <br /> C <br /> I FAC LITY ADDRESS SITE PHONE # with AREA CODE <br /> L �. <br /> 1 <br /> T CITY, STATE ZIP CODE M of TANKS - <br /> Y _-1 - V, .�) , at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> 1 NAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N CITY STATE ZIP CODE TYPE of PPLICATION ., <br /> T "r I 1A C1 �_ �, — , r CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1908 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I $ <br /> V <br /> E TANK FEE = 150.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 0 Tanks = 'I 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply y fee for <br /> C each year appllcabLe) S <br /> I <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California N i S Code, Section 25287 <br /> I <br /> Tj # Tanks ` x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> f ' <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE f53.00 per hour (3 hours minimum per TANK) # TANK(s) "L % 0 = �� <br /> 0 <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspects ons) TANK I.D. f(s) <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK N TANK(s) _ X 5150.00 S <br /> P PLAN CHECK (Install. Plan Review i Construction Inspections) TANK I.D. f(s) <br /> L <br /> AlN PLAN CHECK FEE - S53.00 per hour (8 hours minimum per Facility) = S424.00 minimm S <br /> R REPAIR FEE (workplan review i constructl on inspections) TANK I.D. #(s) <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimu VTANK) f TANK(,) _ X 5159.00 S <br /> A <br /> R PIPING REPAIR FEE $53.00 per hour (3 hour minimum per facility = S159.00) S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $53.001Ar S <br /> 1 <br /> C CONSULTATION FEE = S53.00/hr SAMPLING INSPECTION FEE = $53.00/hr S <br /> .IGH':�!I!!mmm!m!e!!mmm�mmmmNmmm!!mmmmoNm!mmiNmemnmmm!nmmn ��I! mFnmmn�>mm!Inmvn ro D�mmm!m�!mm — - - <br /> : ......:..... ::a:.....:!.:,1:, .I.wl ..__...._. .._... <br /> w ImL::i.V:. .ly ym,-;...1:..,, ::. AM DATE. <br /> SEP$ ! , CtllIY1U'�E� # 'SOL' �WS�E }51'51' �$b� AN(yJ11T RIND� CIfEC� �AStr C�1V'�IS WY OATS �1:L'i'IVC'6 <br /> iii:� .:.m...:.l:.Nem!mmmm!v!..mmmmmmm�mnmmmn_em!mmlmnmmmm! .... ... ..mnm.mil mminnn.......... <br /> l <br /> .. !mmmlmmmmm <br /> i[::,: <br /> mnlN! <br /> :i9iiiHl:JiiIJauiiitdl'J':NNL111!W:1WNIi1HIWHHiHWVI01NNiiHHNNHNN11gIIWWNVWNNNHINHuWINVIIII:INFWINNANFINWIIHIXB.IIVIBP:VNllP:WW10NtlJW1iWi1WVV:WNW11iVWHNIVIII1V11G111VIliNNiliNiiiNiN4i11V11Vi1NiiuVNIViWV1iV1111NN'Ju'4i111ii14iaC:6:. <br /> EH 23 032 (Revised 4/8/91) Page 11 <br /> O <br />