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'%� ... .� <br /> . SAM JOADUIN COU PIMILIC MEA(LTH SERVICES - EMVIROINENTAL ME DIVSION - <br /> 1MDENGROU D STORAGE TANK PROGRAM - FEE WaRKSIIEET <br /> S FACILITY SITE HANE FACILITY CONTACT NAME <br /> T ( l/ Ia A) <br /> E FACILITY A06RESS .SITE PHONE # with AREA CODE <br /> i /o Au��-T n,�N ,� Z — 3S- 2elro <br /> CITY STATE ZIP CODE # of TANKS <br /> A I (�- 953 <br /> P at SITE 3 <br /> P APPLICANT/BILLING NAME _ APPLICANT CONTACT NAME <br /> L <br /> 1nqe / G 11,Cie <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> NCdQ, _ _ Gc <br /> 7-0 <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> AQ,AC'C CA 5— (Closure ^^•-� ��:.^'--r-��� <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to Jarxmry 1, 1991) = 5100.D0 1986 1987 1988 1989 1990 A gf <br /> A <br /> C S kFBurST' <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX S <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1 1996 , <br /> F (multiply # by fee for <br /> i C each year applicable) S <br /> 1 TANK PENALTY FEES ASSESSED XxXX XXXX S <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> 14(Enter amount and year) <br /> C PERMANENT CLOSURE (Removal. or Authorized losure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S -7020= <br /> 5 <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(a) �- <br /> R <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X 5234.00 = S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) �— <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours mininuNFACILITY) $624.00 minirtam S <br /> R REPAIR FEE (Workplan Review i Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours miniuLWFACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 278.00/hr S <br /> I <br /> si I I C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S 4er' <br /> TOTAL DUE S <br />: <br /> FOR OFFICE USE ONLY <br /> `. <br /> M SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED I CHECK #/CASH RECEIVED BY DATE RECEIVED <br />