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C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />$ <br />O <br />' <br />CITY <br />$ <br />STATE <br />ZIP CODEWbf TANKS <br />R <br />A <br />`la"4-— <br />TANK I.D. #(s) <br />R <br />at SITE <br />PIPING REPAIR FEE <br />E <br />P <br />$234.00 minimum $ <br />TRANSFER FEE s <br />$20.00 UNAUTHORIZED RELEASE EVALUATION <br />= $78.00/hr <br />$ <br />P <br />APPLICA /BILLING NAME <br />APPLICANT CONTACT NAME <br />S <br />`y <br />C <br />CONSULTATION FEE _ <br />I <br />= S78.00/hr <br />$ <br />U <br />G <br />TOTAL DUI: <br />C <br />MAILING ADDRESS <br />FOR <br />OFFICE USE ONLY <br />APPLICANT PHONf # WITH AREA CODE <br />A <br />N <br />O <br />T <br />CITY <br />STATE <br />ZtP CODE TYPE of APPLICATION <br />y(Closure, <br />Installation, etc.) r <br />TOTAL <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br />XXXX <br />xxxx <br />XXXX <br />xxxx <br />xxxx <br />$ XXxxxxxxxxxxx <br />A <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (if Applicable) <br />XXXX <br />XXXX <br />xxxx <br />XXXX <br />XXXX <br />S xxxxxxxxxxxxx <br />I <br />V <br />TANK FEE _ $50.00/TANK (Prior <br />to January 1,1991) <br />$170/TANK (After January 1, 1991) <br />E <br /># Tanks = 1986 <br />1987 1988 <br />1989 1990 <br />1991 1992 1993 1994 <br />1995 1996 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) XXXX <br />XXXx xxxx <br />xxxx XXXX <br />S <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ <br />L <br />I <br />STATE SURCHARGE = S56.00 each TANK <br />(Due every 5 <br />years) See <br />California H & S Code, Section 25287 <br />T <br />T <br /># Tanks x $56.00 <br />1988 through <br />1990 <br />1991 through 1996 <br />(Enter amount and year) <br />$ <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />$ <br />O <br />CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) <br /># TANK(s)_ X $234.00 = <br />$ <br />S <br />/ <br />R <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />PIPING REPAIR FEE <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours mini /FACILITY) 1 <br />$234.00 minimum $ <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE = $7$.00/hour (8 hours minim WFACILITY) _ $624.00 minimum $ <br />R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br />E <br />P TANK LINING REPAIR FEE z $78 00/hour 13 h r <br />A <br />4U s mini m/TANK) # <br />TANK(s) x 9234.00 = <br />�^ <br />$ <br />I <br />TANK RETROFIT REPAIR <br />FEE = $78.00/hour (3 hours min./FACILITY) = <br />$234.00 minimum <br />$ <br />/ <br />R <br />Y� <br />PIPING REPAIR FEE <br />_ $78.00/hour (3 hours minimum/FACILITY) = <br />$234.00 minimum <br />S <br />N <br />TRANSFER FEE s <br />$20.00 UNAUTHORIZED RELEASE EVALUATION <br />= $78.00/hr <br />$ <br />I <br />S <br />C <br />CONSULTATION FEE _ <br />$78.00/hr SAMPLING INSPECTION FEE <br />= S78.00/hr <br />$ <br />TOTAL DUI: <br />$ <br />\ <br />U <br />FOR <br />OFFICE USE ONLY <br />e <br />DIST <br />$ <br />CHECK #/CASH RECEIVED -BY <br />E DATE RECEI <br />