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Y <br /> SAA d011011N WAITY PUBLIC NEALTN SBRVICEB - ENIIIROUMTAL NEALTN DIVSION <br /> UNIMMOAAtDMOAN <br /> ltORASMt tAT1if /ROSRM FEE VORKSNEET <br /> S FACILITY SITE NAME FACILITY CONTACT WANE , <br /> T /27A <br /> E FACILITY ADDRESS <br /> SI!f PHONE 0 With AREA CODE <br /> CITY _ /' STATE T CODE 0 <br /> C of TANK <br /> t,,: <br /> k <br /> D <br /> A <br /> /Oc%� p �cL) at SITE' <br /> P APPLICANT/BILLING NAME APPLICANT CON>ACt NAME <br /> L r��tir r �'�v��i �J'i, h E LTh <br /> 1 ���` ,urs <br /> 14 <br /> C MAILING ADDRESS APPLICANT ONE 0 WITH AREA COD �` ,t <br /> A . <br /> 1 CITY STATE t P CODE TYPE of AP <br /> (Ctosure =Irmwetttationetc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to J 3 1►w <br /> A 1) : (100.00 ' 1986 1987 1988 1989, 1990 <br /> C ! <br /> T FACILITY PENALTY FEES ASSESS Cable) XXXXXXXX ! <br /> 1 . <br /> V TANK FEE _ 650.00/TANK ( i to dbnuary 1, <br /> E 199 1170/TANK (After January 1, 1991) <br /> 0 Tanks = 1987 1988 1 1991 1992 1993 1994 1995 1946 <br /> F (multiply W-6jfee for <br /> A each year apptieable) ! <br /> C <br /> I TANK PENALTY FEES ASSESSED X1OIA ! <br /> L <br /> 1 STATE SURCHARGE ■ 156.00 each TANK DUO every Yeti ) !e0 Californis N ti S Code. Section 25287 <br /> T <br /> Y 0 Tanks x 156.00986 r 990 1991 through 1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (ReMwI l or AutfWjg6d Cleae•in•pleoi)' TANK I.D. 0(s) <br /> L <br /> 0 CLOSURE FEE • 1178.00/hour (3 hoUMt mini ANK) 0 TANK(s) X !234.00 • _ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Ift Wtl <br /> R ) TANK I.D. 0(s) <br /> E TEMPORARY CLOSURE FEE • 078.00/he11M Y3 Dura minlmup/tANK) 0 TANK(a) X !234.00 • ! <br /> P INSTALLATION PLAN CHECK (Plan j@V16"A COMtrUetion InapeetiDns) TANK I.D. 0(s) <br /> L <br /> A <br /> N PLAN CHECK FEE • 1178.00/hour (8 h s minimum/FACILITY) • !624.00 minimum ! <br /> R REPAIR FEE (Workpten Review s ftlw+ctloh Inspections) TANK 1.0. 0(a) <br /> E <br /> P TANK LINING REPAIR FEE a !78 /16W (3 hours minimum/TANK) 0 TANK(*) X !234.00 • ! <br /> A <br /> I TANK RETROFIT REPAIR FEE + 78.00/hour (3 hours min./FACILItY) • !234.00 minimum <br /> R <br /> PIPING REPAIR FEE • S78. /hour Whears mfnlmum/FACiLItY) ' • 1234.00 minfmun ! <br /> N TRANSFER FEE • !20.00 1 JUNAUTHORIZED RELEASE #VALUATION + !78 <br /> I .00/hr ! <br /> S <br /> C CONSULTATION FEE = S78.00/hrLINO INSPECTLON FEE • 1178.00/hr ! <br /> TOTAL DLR: ! 3 5/c <br /> FOR OFFICE USE ONLY <br /> wa—mst 1-11 1 <br /> SWEEPS 0 COMPUTER 0 LOC CODE *DIST CODE AMOUNT RECEIVED CNECK 0/CASH RECEIVED It <br /> DATE RECEIVED <br /> NIM.H ! <br /> EH 23 032 (REVISED 11-1.92) ._ C„ <br />