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gam F-ee-s <br /> -F� NVENVIRONMENTAL OIVSICN /Y1l J 9/7l, <br /> t"K- SANlOAWIN CST� <br /> UjWGRU= ORAGETANKPROGRANEWCKSHEElW <br /> rA lLI^TY CONTACT NAME <br /> SI fAC(�ITIYY,1 S T/EJ1 NAME I US�u Y� - /`n V <br /> SITE PHON k with AREA CODE <br /> E FACILITY ADORESS \ II0 L',&( NI <br /> yoz �1 W <br /> & S ATE ZIP CODE x of TANKS <br /> CITY I 5 L O Z <br /> at SITE <br /> A APPLI NT CONTACT MAKE <br /> {, <br /> [ APgq[ T/BILL G c „l/,1-�_ G rl Y/� � VFv I//�"v 1 v <br /> APPLICANT PHONE it utT'�AREA CODE <br /> G NAILl911255S N G I Dore <br /> A <br /> N STATE ZIP CODE TY APPLICATION <br /> TI CITY q✓"ZD Z-�, (Closure meta Nation, etc.) <br /> nc� `1 TOTAL <br /> 1986 11987 11988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior :o January 1, 1991) = 5100.00 X)IXX XXXX I [06 I l00 5 ZDD <br /> AOZ <br /> G I XXxX I xxxx 1100110 O s 'L D 9 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) 1 1991) <br /> I 5170/TANK (After January <br /> 1 <br /> y TANK FEE z 550.00/TANK (Prior to January ,1991) <br /> E 1986 11987 11988 11989 I '990 1991 1992 11993 11994 11995 11996 G'1/ <br /> I Tanks = I I s 6 10 /�` <br /> F (multiply x oy cr_ for I I I � GD I� '�DI <br /> Al each yeal ar applicable) %XXX %XXX :J / I I S �0/O q <br /> { TANK PENALTY -FEES ASSESSED I XXXX I %XXX I I �D 5b l7 v 1,I <br /> L; ch TANK (Due every i years) See California N S S Code, Section 25287 <br /> 11 STATE SURCHARGE _ 356.00 ea <br /> T� 1988 through 1990 1991 through 1 6 <br /> Y x Tanks l x 556.00 5& S // Z— <br /> / Z fie/ <br /> (Enter amount and Year) C <br /> to J <br /> Cj PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Ptace) I TANK I.D. x(a) 5 <br /> imm/TANK) <br /> L I d TAWS)__ X 5234.00 = <br /> 0CLOSURE FEE : 578.00/hour (3 hours min <br /> Si I TANK I.D. 40) <br /> V TEMPORARY CLOSURE (Plan Revier 3 Inspections) s <br /> R 5234.00 mi ninum <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACIL ITY) <br /> PI INSTALLATION PLAN CHECK (Plan levier 3 Construction Insoeetions)I TANK I.D. it(s) <br /> L. s <br /> PLAN CHECK FEE A = = s78.00/hour (8 hours minimam/FACILITY) z 5624.00 minimus <br /> NI • . <br /> RI REPAIR FEE (Workplan Revier i Construction [nspecTANK L0. !(s) <br /> ions) s <br /> E' :EE = 578.00/hour (3 hours minim RVTANK) I R fANK(s) X 5234.00 = <br /> P LANK LINING REPAIR 5 <br /> A = 3234.00 minimum <br /> i TANK RETROFIT .REPAIR FEE = s78.00/hour (3 hours min./FACILITY) <br /> PIPING REPAIR FE. 5 <br /> R z 378.00/hour (3 hours minimm/FACILITY) = 5234.00 minimume <br /> 520.00 UNAUTHORIZED RELEASE VALUATION E z 578.00/hr I I S <br /> NI TRANSFER FEE = I <br /> I 1 <br /> I ( I 5 <br /> sIAPLING INSPECTION FEE z S78.00/hr <br /> CI CONSULTATION FEE S78.00/hr <br /> TOTAL DUE 5 <br /> FOR OFFICE USE ONLY _ -- -- - <br /> SWEEPS x COMPUTER LOC -ODE DIST CODE AMOUNT RECEIVED CHECK ?/GSM REC.iVED 3Y <br /> DATE RECEIVED <br /> 5 <br /> "H 23 (REVISED10-28.93)=�=•——- • <br />