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SAH JOAOUIM cotom PUBLIC HEALTH SERVICES - ENVIRCNliENTAL HEALTH 0tV3ION <br /> UNDeRGR UP0 STORAGE TANK PROMAM - €E5 WORK5HM <br /> Si FACILITY SITE <br /> E FACT ITY CONTACT NANE <br /> I 5 G Sti ��� 4 D <br /> T <br /> E FACILITY A0099SS SITE. PHONE # with AREA 600E <br /> & Z 7-040V L- D, ,� -- <br /> CITY STA 11kZ14 COOS �M of TANKS <br /> A jr ar SITS <br /> P1 lKJlLV <br /> .P APPLICANT/BILLING N APP tCANT TACT NAME <br /> L O C i Zy WPrTE Lu±tj VbRSG <br /> I <br /> C MAILING A00RilSSJL ��� APPLICANT PHONE/ � H AREA C <br /> A L l((J> I <br /> >! _ <br /> T CI \ , STATE ZIP CODt< TYPE of APPLICATION ����t ©Iptr <br /> Ci7�-Z. (Closure; Installation, ete. <br /> TOTAL <br /> 1986 19a7 39$8 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) 5100.00 <br /> A )x== xxXx x <br /> C <br /> T FACILITY PENALTY €EES ASSESSED (If Appliagote) XXXX 44 X)C)OC 9 <br /> I 1 <br /> V TANK FEE n 350.00/TANK (Prior to Jai+usry 1,1991) 5170/YANK (After January 1, 1941) <br /> E <br /> Yanks = 1956 ! 1957 ; 1988 M 1989 1990 1991 1992 1943 t 1994 1995 1 1996 <br /> F (multiply s t)y fee For I <br /> A each year applicable) XXXX XXXX ; <br /> G ` <br /> I TANK PENALTY FEES ASSESSED xxxx XXxx S <br /> L <br /> 11 STATE SURCHARGE = $56.00 each TANK (Due very 5 years) See California H b S Code, Section.WS7 <br /> T <br /> Y # Tanks x 556.00 19$8 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Ramovat or Authorized Ctnsure+-in-Ptace) i TANK I.O. $(s) <br /> L <br /> 0� CLOSURE FES = 57$.00/hour (3 hours minimtmVTANK) 0 TANKCs) X 5234.00 = t; <br /> S <br /> Ul TEMPORARY CLOSURE (Ptah Review & inspections) TANK I.D. #(.$) <br /> R <br /> E TEMPORARY CLOSURE €EE = 578.00/hour (3 hours ainitaua/fACILITY) 5234.00 minian 1" <br /> P� INSTALLATION PLAN CHECK Man Review g Construction Inspections) TANK I.O. #(s) <br /> L <br /> A n�y1 <br /> K PLAN CHECK FEE 378.00/hour C8 hours MinimWFAC:ILITY) = $624.00 minimus S <br /> R REPAIR FEE (workplan Review Z. Construction Tnstxetionsl � TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE' = s78.00/hour (3 lxtui`S einiaWTANK) � it TANK(t) X 5234.00 = i <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour C3 hours min./FACILITY) = S234.00 minimus S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour C3 hours ainfaLWFACILITY) = 3234.00 minimun s <br /> MI TRANSFER FEE s 520.00 UNAUTsoRl= RELEASE EVALUATION = S78.00/he � . 3 <br /> I � <br /> S <br /> C CCNSULTATICN FEE a 573.00/hr I SAMPLING INSPECTION FEE = 57$.00/hr L <br /> TOTAL OUIE 5 <br /> F02 OFFIC2 USE ONLT ' <br /> M. SWEEPS A COMPUTER 1 LOC COOS GIST =E AMOUNT RE=-IVED CHECK »/CASH RECEIVED 3Y TATE atiCEIVED <br /> - r � <br /> ual <br />