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SAM JOAQUIN29aimaL <br /> IC HEALTH SERVICES - ENVIRONMENTAL HEAL16VSION <br /> STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SIT NAME I FACILITY CONTACT NAME <br /> I 1 ki 4 ri '�/�, /l/'—/ <br /> T rr , W <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & s CLA-C'Vl\ �' - eyZ67 <br /> CITY STATE ZIP CODE # of TANKS <br /> A0 <br /> Ct 95G at SITE <br /> P <br /> P APPLICANT/BILLING//NAME 'll11 APPLICANT CONTACT NAME <br /> L �/a �TY� c/! !��v�C G s►7 C- <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N <br /> T CITY t STATE ZIP CODE TYPE of APPLICATION lam'S k rt <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx $ <br /> 1 <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After ,January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) $ <br /> C <br /> 1 TANK PENALTY FEES ASSESSED I xxxx xxxx ILS <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1986 through 1999 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) -L- X $234.00 = S L� <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X S7_34.00 = S- <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br /> R REPAIR FLEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 378.00/hour (3 hours minima/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> 1 <br /> S - <br /> C COt5ULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr S <br /> TOTAL DUE $ 67 <br /> FOR OFFICE USE ONLY <br /> ---...._.._.........._...._...__.____._ r —�_ ----- -------.._.__ .,, _�--:--.--...... <br /> .......--..._._ --....._.__..._._._.._....... __. ..._._.__ _.. ._. ... ......_.. _ <br /> .�ri�;;w�� �:,,.:..�:��. .._.-_e.._-_..-:-. ,. _..w. __......,-,- • �-...�.�R�;:s;;;:•�;;;a;c���au�:,,,._.� ati:��'ss<'a <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> ------------------ <br /> 4 - <br /> 5 S <br /> ZG <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />