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• SAN 10Am IN �A y PUBLIC NEALTN SERVICES - ENVIIINMITAL -11TH DIVSION <br /> , AROICIM STORAGE TAIB PROGRAM - FEE WORKUk 00, <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> ( v <br /> T .SITE PHONE # with AREA CODE <br /> E FACILITY A06RESS Z 3S- 6 O <br /> G <br /> i STATE .ZIP CODE # of TANKS <br /> CITY i�L G�s3 at SITE <br /> Ac.i7 <br /> PI-MAPPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L G L <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C NAILING ADDRESS _ Z14 <br /> A [JD, <br /> 53.3 6 <br /> a STATE ZIP CODE TYPE of APPLICATION <br /> T CITY G /� S_ (Closure, '^ ' 'aitaa+sc� <br /> RA c /0 TOTAL <br /> 1986 1987 1988 1989 1990 if <br /> ANNUAL FACILITY FEE (Prior to Jarwary i, 1991) $100.00 f �1�AULST <br /> A <br /> C xxxx xxxx f <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I 5170/TANK (After January 1, 1991) <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) <br /> E <br /> # Tanks = _ 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1 <br /> F (multiply # by fee for S N <br /> Aeach year applicable) <br /> C $ <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX <br /> L <br /> 1 STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 2528 <br /> T 1986 through 1990 1991 through 1996 <br /> Y # Tanks x $56.00 �p <br /> (Enter 'mount and year) 6 S <br /> C PERMANENT CLOSURE (Removal or Authorized tosure-in-Place) TANK I.D. #(s) c <br /> L # TANK(s) �_ X 5234.00 - $ -7p2 <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) <br /> STANK I.D. #(a) <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) <br /> R <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minim m/TANK) # TANK(s)_ X 5234.00 $ <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(a) <br /> - <br /> A <br /> A 5624.00 minimum $ <br /> M PLAN CHECK FEE = 278.00/hour (8 hours minimum/FACILITY)CITY) <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.O. #(s) <br /> E X $234.00 S <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) ,_ ` <br /> A = $234.00 minimus S <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br /> a = $234.00 minimus S <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minisus/FACILITY) <br /> ALP- <br /> M TRANSFER FEE _ $20.00 <br /> UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> I <br /> S = $78.00/hr $ <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE O� <br /> TOTAL DUE $ � <br /> FOR OFFICE USE ON _ ... .__...,_....�.,._.__— =�=!__== <br /> .._ <br /> ED <br /> BY RECEIV <br /> BY DATE <br /> _ SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED <br /> EH 23 032 (REVISED 11-1-92) Page <br />