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SAX JCAOUIH TT PI.BLIC HEALTH SERVICES - ENVIRCNME1TkL TH DIVSICN <br /> t+..,,E,tt MM SiCRAGE TANK PROGRAX - FEE XR7SHEL- <br /> Sl FACILITY ITE NAME -T s Gf�s I FACILITY CONTACT NAME <br /> E FACILITY ADDRESS SITE PHONE # with AREA CSE <br /> 7 QRZ <br /> CITYi/` I .IP CCOE # of TANKS <br /> A /fSi at SITE <br /> P <br /> P APPLICANT-413ILLING NAME I APPLICANT CONTACT NAME <br /> L <br /> C MAILING ADORESS APPLICANT PHONE S WITH AREA CCOE <br /> M <br /> T CITY C LTATEI ZIPEI TYPE of AP ` <br /> K�l1—�`•',Y_`"i <br /> (Closure, Installation, 'tc.) _//� <br /> TOTAL <br /> 1986 1987 1988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1941) = 5100.00 <br /> A )C= XXX:( S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Apel:•oble) I Xc= I rca I I I S <br /> I <br /> 11 TANK FEE = 550.00/TANK (Prior = :amary 1,1991) 5170/TANK (After January 1, 1991) <br /> C <br /> S Tanks = 1986 1141;7 11988 1989 11990 11991 11992 1993 11994 11995 11996 <br /> F (multiply fee for <br /> A each year applicable) XXXX I I I I I 11701 I S f <br /> C' <br /> I TANK PENALTY FEES ASSESSED I XXX= <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK Crsz every 5 years) See California H I S Code, Section 25287 <br /> T <br /> T : Tanks x 556.00 ISM through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> C1 PERMANENT CLOSURE (Removal or Authorized osure-in-P(aca) I TANK I.D. 4(s) <br /> LI <br /> 01 CLOSURE FEE = 578.00/hour (3 hours sini=.c/TANK) I TANKCs) X 5234.00 = S <br /> S' <br /> U IE PCRARY CLOSURE (Plan Review 3 Irssactions) I TANK I.D. ;$(s) <br /> R <br /> E�IPCURY CLOSURE F=EE - 578.00/hour C3 :.curs aini-- FAC, I 5734.00 minimum S <br /> P1 INSTALLATION PUN CHECK (Plan Review Csestruetian Inspections) TANK I.D. :(s) <br /> L <br /> A <br /> 11 PUN CHECK FCS = 578.00/hour (8 hours zinimam/FACILITY) = 5624.00 mini=.= S <br /> Z� REPAIR FEE (Workplan Review L Comtrj=.cn Ir=ections) I TANK I.J. t(s) <br /> =i <br /> P TANK LINING ,REPAIR FEE = 578.00/hour C3 :^.curs minimum/TANK) I # TANKCs) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR F' - 578.00/harr 13 hours min./FACILITY) = 5234.00 mini== S <br /> R <br /> PIPING REPAIR FEE = 578.001hour (3 Wass ainim.m/FACILITY) = 5234.00 minimum S <br /> 71+ TRANSFE..R F.. = 520.00 I I '.DUulT'h211M RELEASE EVALUATION s 378.00/hr I I S <br /> II <br /> S <br /> C� CONSULTATION FE_ = 578.001hr I i SAM--IXG INSPECTION FEE = 578.00/hr I S <br /> '�, Ll TOTAL DUE3 <br /> FOR OFFTCE USE CULT <br /> SLEEPS I CGMPUTE.2 I LOC C`'AE I DIST CODE :MCUNT .RECEIVEO CHEF :/GASH I RECEIVED 3Y I GATEE'= <br /> RI'rE] <br /> _H Z3 032 (REIISM 10-23-93) ✓�V �� Page i <br />