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S FACILITY SITE NAME FACILITY CONTACT NAME <br /> Ir U ✓tocxQ s+rA� v� olz3 Al <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & X03 G2 �rll Ave. NSA <br /> CITY STATE ZIP CODE # of YANKS -7 <br /> A Tra�� Gq at SITE Z <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L ()Aocoj Cor orti'i0V\ Ed Kals!-o•% <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A 200o Lf"ow GalnyovL P�4ce, 5.,;-�tcfoo 510-2'��-Z311 <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> SOLn �0,wtOLn G!4 �jys$"3 ( Closure, Installation, etc.) <br /> TOTAL <br /> 7986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A %%%X XXXX XXxx Xxxx XXXX S XXX%XXX)=XXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %XXX XXXX XXXX XXXX Xxxx S xxxxxxxxx%X%X <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 2— 1986 1987 i 1988 1989 1990 1991 1 1992 1993j1995 1996 <br /> F (multiply #by fee for U <br /> A each year applicable) XXX% xx%X %%%X XXXX XXXX 310 Slip 3�d 140 34D $ ac)90- <br /> c <br /> I TANK PENALTY FEES ASSESSED XXXX Xxxx XXXX XXX% xm Sq t) 3yo 5yo 340 3y0 $ ')-0 Ll C) <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California M & S Code, Section 25287 <br /> T <br /> Y # Tanks 7- x 556.00 1988 through 1990 1991 through 1996 e , .�„ <br /> (Enter amount and year) , <br /> "` V <br /> 112 � 1Z $ �a <br /> C PERMANENT CLOSURE (Removal or Authorised CL osure-in-Place) TANK LO. #(s) <br /> L _ <br /> D CLOSURE FEE . 578.00/hour (3 hours minimum/TANK) I # TANK(s) Z X $234.00 = S y 8 <br /> S <br /> Ul TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> EI TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimus/FACILITY) $234.00 mini mum S <br /> PINSTALLATION PLAN CHECK (Plan Review & Construction Inspecti ons TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimun/FACtLITY) = $624.00 mini mon S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D_ #(s) <br /> E <br /> P TANK LINING REPAIR FEE - 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5734.00 mini mux S <br /> II <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimus/FACILITY) = 5234.00 mini mum S <br /> M TRANSFER FEE = 520.00 UNAUTROR12EO RELEASE EVALUATION = $78.00/hr 5 <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S - \ <br /> TOTAL WO <br /> FOR OFFICE USE ONLY l <br /> __ _ _ __._.._. __ .. _ -an sm:amrvusmmas r :. a <br /> _... <br /> _. .::._.____.,.: I RECEIVED <br /> _.. :.._. _ <br /> SWEEPS # COMPUTER # LOC COME DIST CODE AMOUNT RECEIVED CHECK #/CASX RECE IVFO 8Y 0 RECFIYED <br /> Lad S <br /> E 'd W02id WO'17D:O 966L—L0—L <br />