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UNCERGRCL'NO STORAGE TANK PROGRAM FEE WORKSHEET <br /> FFACILITY SITE NAME FACILITY CONTAWAME <br /> T GranT ;,c Teas a- ooOf RW WH"'M -2 <br /> E ,FACILITY ADDRESS SITE PHONE a with AREA CODE <br /> L ;l q .26 Lu (-ra •,,I zinc. 2c -A ao9 3a -- B = ?-3 <br /> CITY STATE IIP CODE�7� / I of TANKS 7 ni 5 P r o St G t <br /> A TrGLG y �. � ls3T6 at SITE i <br /> •1 s dor hi a on <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME �- <br /> L weA I =oo r z udc --ems <br /> C NAILING ADDRESS APPLICANT PHONE S WITH AREA CLUE <br /> A 43 R'slca La c � Pno, Gov. <br /> T CITY 1` STATE ZIP CODE TYPE of APPLICATION — <br /> W OST .$0.r- It 6L. /,,If:A 4`D G 956 �/ � (Closure, Installation, e <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 <br /> A 5 <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX x700 S l/p <br /> I <br /> `F TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> ? Tanks • 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply x byby fee for <br /> A each year applicable) I S <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx X= S <br /> L <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H b S Code, Section 25287 <br /> T d Tanks X 256.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. A(s) <br /> L / <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimLrVTANK) d TANK(s) X 5234.00 = S !JJ U <br /> S <br /> U TEMPORARY CLOSURE (Plan Review d Inspections) TANK I.D. d(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) • $234.00 minimum S /'J,//4' <br /> P INSTALLATION PLAN CHECK (Plan Review b Construction Inspections) TANK I.D. 0(s) 2 3 <br /> L <br /> A <br /> N PLAN CHECK FEE a 278.00/hour (8 hours minimum/FACILITY) = $624.00 minim m S NSA <br /> R REPAIR FEE (Workplan Review L Construction Inspections) TANK I.D. 0(a) <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minlman/TANK) M TANK(s) _ X 5234.00 S 1)1,4 <br /> A <br /> i TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min-/FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE a 578.00/hour (3 hours miniaWFACILITY) • $234.00 mini" S — <br /> M TRANSFER FEE a $20.00 1A111U12RCRIZED RELEASE EVALUATION a 578.00/hr <br /> I <br /> S <br /> C CONSULTATION FEE a 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE 5 — <br /> I <br /> FOR OFFICE USE ONLY __ ___ <br /> ...:..T�ggw.wG <br /> as�SLm''c�PS'T'"'I'Rac�'d+l7Y€4E"T L'�C�L�c )'DIS�L���E9V� C�In"a'��i(.�L�E'6'�I"�'��mU'XR�t�it'EC<:IVEu mrw <br /> • }ll <br /> a n � <br /> a <br /> mmaia aiarairsitawmwaaaww rafamraxararwrsrrwnwssrmisiaaowsiiwsairis rwa:rais wa rsmssmiw wssisas:a.risisis's <br /> EH 23 032 (REVISED 3-1.931 <br />