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VIVUCI' 0r vL/IVL. 01 VRY1l.7C Ip%lvm rrvl.117rV'UVI 1 L " vvviln.n I � <br /> FACILITY NAMEFACILIT )NTACT NAME <br /> FACILITY ADDRESS SITE,PHONE#WITH AREA CODE <br /> 93 S-�545; <br /> CITY STATE ZIP CODE #OFF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Installation Repair Retrofit <br /> ACTWE FACILITY <br /> 1997- 999 2000 2001 2002 <br /> SWO FEE INCLUDES FACILITY FEE+I TANK (SI70)X(#W, )X(#a� .ePPI.Mble) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> .. I <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SUR CHARGE=$10/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILRIES NOT ALREADY ON INVENTOR.- 1N A CUPA PROGRAM X17.50/FACILITY <br /> PERMANENT CLOSURE - <br /> (Removal or Permitted Closure in Place <br /> $ <br /> TANK ID# s): CLOSURE ' -E=5267/TANK #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORA,, CLOSURE FEE=S267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Chedc and Construction Inspections) <br /> $ <br /> TANK ID#(s): Pl, CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267 <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> PIPING REPAIR FEE _$267/FACILITY _ <br /> MISCELLANEOUS <br /> TRANSFER FEE = $20 <br /> $ <br /> CONSULTATION FEE = S 89/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 89/HOUR <br /> SAMPLING INSPECTION FEE = S 89/HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECKS I RECEIVED BY DATE RECENED <br /> SR <br /> EH 23 032(REVISED 3/75102) <br />