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a�*IAA AN <br /> SAA JOAQUIN qMlY PUBLIC HEALTH SERVICES - ENV% <br /> RSTORAGE TANK PROGRAM - IEE WORKSHEET <br /> 1 Ci <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I C f-4 942-75 f�' 1. a <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & z9 o �NrA V4AI(0 Pocam- be. ?-OR- y7S-s 55 <br /> CITY STATE ZIP CODE # of TANKS <br /> A J4'C)C.1CC& 95Zo? at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME m <br /> Lf) kulyxcjsPAN Gq E L-C <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A5 p 2.- 00.E <br /> N <br /> T CITY• STATE ZIP CODE TYPE of APPLICATION <br /> 9�S$3_OL,O (Closure, tnstaltation, etc.) 4Pioo a(` <br /> TOTAL <br /> 1986 1987 1988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX XXXX XXXX XXXX S XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX S XXXXX)O=)O(XX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks 1986 1987 1988 1989 11990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year appticabte) XXXX XXXX XXXX XXXX XXXX S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX I XXXX I I S <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x S56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) I # TANK(§) X S234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & inspections) I TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Ptan Review & Construction Inspections)I TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = S <br /> A tt'' <br /> I TANK RETROFIT REPAIR FES = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R 1 <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> N TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = $78.00/hr ( SAMPLING INSPECTION FEE = S78.00/hr S . <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> OEM <br /> .c�_._r�._"___'__.. .... •_.. <br /> SWEEPS # COMPUTER # ( LOC CODE I DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY I DATE RECEIVED M. <br /> .......__............ _...___. <br />