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ENVIRONMENTAL HEALTH OIVISION p <br /> n UNOERGRC .I STORAGE TANK PROGRAM FEE WORKSHEET Vo�K �2uS <br /> a <br /> FACtLIT;`'SITE NAME �/]n �r n FACILITY CONTACT NATE <br /> " F F'f G /��FLG�GG <br /> C SITE PHONE X with AREA CODE <br /> ( FACILITY ADDRESS <br /> L <br /> STATE ZIP CODE Z of TANKS ( - <br /> T CITY� �` / 9 at SITE / <br /> A (�IAAPPFPLLI�CANNT�/91LLING NA��M/E//�J���/�/!'r y�/tA <br /> APPLICANT nC,aO�N,TA�C•T NAME y/�� <br /> P ('(P/IX�VI.I / YUJVtGW�'T� i J {'l ^ , �X�/C-uI <br /> 1 MAI NG ADDRESS APPLICANT PH�E t WITH AREA CODE <br /> I KA!�NG ADOR <br /> C G'Sv, <br /> A - STATE ZIP COO TYPE of APPLICATION c31/lI nu TCTti IL.��� <br /> N CITY % - / i/ CLOSURE, INSTALLATION, etc. T <br /> T /f•^1Vt V� 7.�7 Gx At� <br /> TOTAL <br /> ��L <br /> A 1986 1987 )988 1989 1990 <br /> C <br /> AHXUAL FACILITY FEE (Prior to January 1, I991) • 5[00.00 <br /> S <br /> I <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANX Latter January 1, 1991) <br /> F 1 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply 0 by fee For _ _ <br /> C each year applicable) 100 lo—It6c .390 3Y0 <br /> L —STATE = 556.00 each TANK (Due every 5 years) See California N S S [ode, section 25287 <br /> Tr(mTrer —�—c <br /> z 556.00 1986 through 1990 1991 through 1996 <br /> T and year) <br /> PERMANENT CLOSURE (Removal or Authorzed Closure-in-Place) TANK I.O. x(s) (P <br /> C <br /> L CLOSURE FEE = 253.00 per hour C3 hours minin per TAAKY`1" tl TANK(s)_ X $159.00 = S <br /> 0 <br /> S <br /> U TEXPCRAR7 CLOSURE (A onetime permit, for reviewRi..insp<ccians TANK I.D. S(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - 5150-00 each TANK G TANK(s) X 5150.00 = S <br /> F-k <br /> FPLuAg <br /> HECK (install. Plstruction irtsp<cclans) TANK I.O. 0(s) <br /> `y.;7'77HECK FEE - 553.00 per hour (8 hours miniaasa per Facility) - 5424.00 minimus S <br /> 1 <br /> R REPEEii <br /> TANK I.D. 2(s) <br /> E <br /> P TAN (3 hours minimun/TANK) .S TAHX(3) X 5159.00 S <br /> A <br /> I <br /> R PIPON = 553.00 per hour (3 hour minimw per facility • 5159.00) L <br /> 7CFEENSULTATIONS _ UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> = 553.0O/hr FEE = 553.00/hr FEE - S 53.00/hr <br /> TOTAL DUE S <br /> r ... ,,.. <br /> OFFICE USE ONLY. . <br /> ....-�����rs..�..r....P...a,......s.r•r.:....P.:..._,._...,.3.»..w.n..rrx....�w.r.........n.��.,....�.����— �.��...���. <br /> pilf'EiS�` 'CP(ND�`i�` �OC'CG�f� 0157 CCOE" A dfXA)T'RC.D' CRECA /CASX"-�iTC•,0' 9Y TCcfrE _ ARITs a: <br /> ` • cam,- ,kIER l D 1 —.�� , - — ---- ---- a <br /> �=3 alaaTf aa�a�J0faaaata�a9{f305=uV:-JO'�953>Si3��1Si�-'.STra..�....:"l:-..'.'.T25:"«�-'3.--��.i��'SC3�-1(Y ':3f it YaJi=Yt�titf�a�aY0ia.a0la <br /> c. 31 nil racv tJAAronl Fe l__ Pao. <br />