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SUI JCACUIN CL.. .Y PUBLIC HEALTH SERVICES - ENVIRCNMENTAL H. I DIVSICN <br /> uwDERc== STORAGE TANK PRCG2AM - FEE WORKSHEET <br /> SI FACILITY SITE NAME- - -7- I FACILITY CONTACT NAME <br /> E FACILITY ADDRESS I SITE PHONE * with AREA CODE <br /> CITY // � ITATE4 ZIP CODE of TANKS <br /> A S 7`?J� � j at SITE <br /> P 1 w ~ <br /> P APPLI NT BILLING gAME I APPLICANT CONTACT NAME <br /> E <br /> I <br /> C MAILING ADDRESS APPLICANT PHCNE 9 WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLIGATiC:M---- <br /> ICA C ���C �� (Closure, Installation, etc.) <br /> TOTAL <br /> 1 <br /> ANNUAL FACILITY FES (Prior to January 1, 1991) = 2100.00 1986 1987 1988 1_1989 1990 <br /> A XXXX XXX( I S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I =xx I =C( <br /> I <br /> 'I TANK FEE = 550.00/TANK (Prior to January 1,1991) 3170/TANK (After January 1, 1991) <br /> ;* Tanks � 1986 11987 11988 1989 11990 1991 11992 11993 1994 11995 1996 <br /> F (multiply � by fez for <br /> A each year applicable) X)CC( � 7(. } S � <br /> C <br /> II TANK PENALTY FEES ASSESSED X)C(X XXXX ( 3 <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Dtx every 5 years) See California 'H 3 S C,-.,-e, Section 25287 <br /> T <br /> Y Y Tanks x 556.00 1988 ;.hrough 1990 1991 through 1996 <br /> (Enter amount and year) <br /> CPERMANENT CLOSURE (RemovaL or AUthori2"ed Closure-in-Place) i TANK 1.0. »(s) <br /> L <br /> 01 CLOSURE FEE - S78.00/hour (3 hours sini==/TANK) I S TANKCs) X 5234.00 = S <br /> S <br /> Ul TEIMPCRARY CLOSURE (P(an Review 3 Inspections) TANK I.O. ;*(s) <br /> R <br /> TEMPCRARY CLOSURE FEE = S78.00/hour (3 'lours ainim m/FACILITY) ` 3234,00 minimum 3 <br /> P+ INSTALLATION PLAN CHECK (Plan .Review i Construction Inspections) TANK I.O. '+(s) <br /> LI <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minim.m/FACILITY) = S624.00 minimus s <br /> RREPAIR FEE (Workplan Review & Canstn ction Inspections) TANK I.3. #(s) <br /> E <br /> Pj TANK LINING REPAIR FEE = 178.00/hour (3 lours .uinimuRVTANK) t TANK(s) X SZ4.00 = S <br /> A <br /> II TANK RETROFIT REPAIR FEE = S78.00/hour (3 lours min./FACILITY) = 5234.00 minimsm S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours ainimsa/FACILITY) = 3234.00 minimum s <br /> 4+ TRANSFER FEE = S20-00 I i- AUTHCRIZED RELEASE _VALUATION = 378.00/hr I 3 <br /> S <br /> Cl CONSULTATION FEE = S78.00/hr I I SAMPLING INSPECTION ;E=- = S78.00/hr I I S <br /> TOTAL DUE 3 " <br /> FOR OFFTCE USE ONLY <br /> SWEEPS CCMPUTER LOC CODE OIST CODE i AMCUNT .RECZI CHECX T/CASH I RECc'iVED 3Y i OATS R£(rIVED a <br /> ---H Z3 032 (REVISED 10-22-93) Page ti <br /> \i ,/ <br />