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10-1.2-1995 62�54F1'. FROM TO 19153719312 F, 11 <br /> JEERGROM'tin uWwlalA dl rY41.iy �n�,n .rayayr.J - gy1RWYJd 1Al IIW.In Yd YJIY� <br /> STORAGE TANK PROGRAM - FEE <br /> TFACILITY SITE N1UtE /4 v FACT CONTACT NAME / <br /> E FACILITY AGGRESS C j SITE P)IONE it with AREA CODE <br /> L <br /> A <br /> CITY 5 TE ZIP CCOE # or TANKS <br /> P �. c-- "'�� at SITE <br /> P APPLICANT/BILLING NAME APPLICANT CtlAC7 i <br /> f /yyy'TTT77 <br /> C MAILING ADDRESS APPLICANT PHONE # w1TN AREA CODE <br /> N �3 t6 <br /> T CITY STINTf� IIP CODE ]CATION <br /> ta((ation, ate..) <br /> TOTAL <br /> 1986 1987 7988 1989 1990 <br /> 4NNUAL FACILITY FEE (Prior to January 1, 1991) a 11(X).00 <br /> A I= XXXX %XXX )0= ; <br /> C <br /> 7 FACILITY P(NALTY FEES ASSESSED (If Applicable) 7D0(X YXYX XXXX XX70( S <br /> E <br /> V TANK FEE = 550.00/TANK (Prior to ianuary 1,1991) Cf70/TANK (After January 1, 1991) <br /> E <br /> 9 Tanks o 1986 1987 198E 1989 1970 1991 1992 1993 1994 1995 1996 <br /> FI (multiply C byby fee for <br /> A each year applicable) XXXx XXXX XXXX XXXX S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX I X10C( XXXX <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) see California H & S Code, Section 25237 <br /> T _ <br /> Y # Tanks `lam. z 556.00 1988 through 1990 1991 through 1996 <br /> nd <br /> (Enter aaount ayea r) <br /> Ci PERMANENT CLOSURE (Reamve( or Authorized Closure-in-Ptace) YANK [.D. #(s) <br /> L <br /> O CLOSURE FEE _ 578,00/hour (3 hours minimum/TAMK) # TANK(s) n X $234.00 2 cC <br /> S <br /> U� TEMPORARY CLOSURE (Plan Review & Inspections) TANK E.A. els) <br /> E TEMPORARY CLOSURE FEE = 378.OD/hour (3 hours Mintmun/FACYI:TY) 5234.00 minimum ; <br /> P INSTALLATION PLAN CHECK (Plan Rev(eY & Construction Inspections) TANK I.D. 9(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 578.00/hour (8 hours minfILM/FACILITY) $624.00 minimum ; <br /> R REPAIR FEE (Vorkptan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LININO REPAIR FEE = s78.00/hour (3 hours minis%m/TANX) C TANK(s) X ;,*4,Dg = S <br /> A <br /> I TANK RETROFIT REPAIR FEF, = 578.001heur (3 hours 2111./FACILITY) c SZ34,C0 minimus ; <br /> R __ <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minio"FACILITY) = $234,00 minimum ; ..r <br /> N TRAMEFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION n S78.OD/hr S <br /> I <br /> s <br /> C CONSULTAYYOI FEE = 578.00/hr SAMPLING In <br /> FEE = 578.00/hr ; <br /> TOTAL DUE S <br /> Fat OFPi[>w USE ONLY <br /> �a"•m:�m�- - — -.v.m...... mmxrssr:�=_^__e�risnuNeuauom_;m�_==____-s,O�uerpmaaa: ` <br /> N sLEERS # COMPUTER tf LOC '"��•,""••-- ate. _� =,a:-.-=r------`_ <br /> _ CSE DisT CODE AMOUNT RE:.E]VED C1fE•CX #!CASH � FECEIVED 0Y DAtE RECEIVED <br /> exmneammn - <br /> EH M 032 (REVISED 4.6-95) <br />