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SA*QUI&NTY PUBLIC HEALTH SERVICES - ENVIR7H DIVISION <br /> UNDERGROIAm STORAGE TANK PROGRAM - FEE <br /> S FACILITY SITE NAME • �� FACILITY CONTACT NAME <br /> I <br /> n to T 1I '� <br /> E FACILITY ADORES �' R,a. SITE PHONE # with AREA CODE <br /> & (/y t <br /> p <br /> CITY'S `/ C 9 E 7.J.R f,�E # of TANKS <br /> 1f C1 �-Tl C.L!IJ- at SITE I <br /> P APPLICIT/B LLI NG NAME APPLI CONTACT NAME RElt /, I' <br /> I <br /> C MAILIN ADDRESS APPLICANT ONE # WITH AREA CODE <br /> N (,-510 so — O'z Pon <br /> T CIT STAT ZIP CODE TY PPLICATION r,4 <br /> CClosure, Installation, etc.) Oq'v't <br /> 6 go f TOTAL <br /> ANNUAL FACILITY FEE (Prior is January 1, 1991) = 5100.00 1986 1987 11988 1989 1990 <br /> A XXXX XXXX I XXXX I XXXX XXXX S XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If applicable) <br /> I XXXX XXXX I XxxX %XXX XXXX S XXXXXXXXXXXXX <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks = 1986 1987 1988 1989 11990 1991 1992 1993 1994 1995 1996 <br /> F (multiply ##by fee for q <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX L L 11 / I1 7D /70 „ S3 <br /> C V L I V <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXX ! II?o1161VL IIA S ; <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 75287 <br /> T <br /> Y # Tanks/ x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) D <br /> SIA/✓ o321 "oslrrD3arl $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK 1.0. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I Al TANK(s) X 5234.00 = S <br /> S nai <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $734.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = E78.00/hour (8 hours minima/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK 1.0. #(s 3 <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) I 0 TANK(s) X 5234.00 = 3 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum 3 <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I S <br /> I <br /> S I <br /> 9 C CONSULTATION FEE = 578.00/hr SAMPLINGINSPECTIONFEE = 578.00/hr I S <br /> (Y TOTAL TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE I DIST CODE AMOUNT RECEIVED CHECK 9/CASH I RECEIVED BY I DATE RECEIVED <br /> I <br />