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D . .j i STORAGE TANK PROGRAuW911FEWORKSHEET <br />FACILITY NAME <br />TANK ID # (s): <br />FACILITY CONTACT NAME <br />�^ <br />" Iv <br />,rte` /_ <br />/ i`- 71-- , -vt G <br />FACILITY ADDRESS <br />APPLICANT <br />SITE PHONE 0 WITH AREA CODE <br />n <br />$ p1(9 <br />AQP PHONE 0 WITH AREA CODE <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />CA <br />�5®� <br />1VsT.T 57- <br />APPLICANT BILLING NAM E <br />TANK ID # (s): <br />APPLICANT CONTACT NAME <br />6 <br />-�` <br />2001 <br />ti� �4 c.p--c_ <br />APPLICANT <br />MAILING ADDRESS <br />n <br />$ p1(9 <br />AQP PHONE 0 WITH AREA CODE <br />e7Ite.-, w <br />! kL <br />- Dpi re <br />CITY <br />STATE <br />CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Vzt dation Repair etrofit <br />711 ` ✓° <br />C, <br />r�ZIP <br />J �� <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $267 / TANK <br />1996-1999 <br />2000 <br />2001 <br />TEMPORARY CLOSURE FEE= S267 / FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />(s 170) X c: Wft) X (iof yeas ) <br />n <br />$ p1(9 <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />$ <br />TAMC PENALTY ASSESSEO <br />$ <br />TANK SURCHARGE = $8 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA COPA PROGRAM= $101 FACILITY <br />PERMANENT CLOSURE <br />Removal or PemWed Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $267 / TANK <br />I # TANKS X $267 = <br />TEMPORARY CLOSURE <br />Plan Review and Inons <br />TANK 10 # (s) : <br />TEMPORARY CLOSURE FEE= S267 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): G7 <br />TANK LINING REPAIR FEE = $267 / TANK <br />i#TANKSX$267= <br />$ <br />TANK RETROFIT REPAIR FEE _ $267 / FACILITY <br />$ <br />PIPING REPAIR FEE = $2671 FACIUTY <br />n <br />$ p1(9 <br />MISCELLANEOUS <br />TRANSFER FEE = $ 20 <br />$ <br />CONSULTATION FEE = $ 89/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 891 HOUR <br />$ <br />SAMPLING INSPECTION FEE = S 891 HOUR <br />we e <br />$ <br />' ... ^mc DAZOW UN Rt1E $49 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WALL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />■ -- —mw� aI * I rAt luIT_JU 1 AMOUNTRECEIYED 1 CHECKS 1 RECEIVED BY I OATERECEIVEU _S <br />SR <br />EH 23 <br />