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jW pU81It HEALTH SERVICES - EpYIRpIMEI[TAL AR DIVSION <br /> SAIL JOAOC Lw �UW � TA>rK PROGRAM - FEE WORKSHE <br /> FAClL1T COH7A 7 NAME <br /> S FACILITY SITE HA�SE ��? }� S <br /> I � \�r�n,.•5] 1'GJ SITE PHONE # with AREA CODEcl' <br /> d <br /> T P`,� f A <br /> E FACILITY ADDRESS <br /> ST TE CODE # of TANKS <br /> `� ���7 � at SITE <br /> CITY , PA1f II�ENT L <br /> A RECEIVED�y APP�lCAN CONTACT NAME <br /> P APPLICANT/BILLING NAME �E`,CjEiVED I r` <br /> IU� APP,,,LICCANN PHONE L#JLlITH AREA CODE <br /> L MAILING ADDRESS A JQAQ'�3} "';.;;i',Y (7,M �� <br /> A q _ �. :.-- ` '' TYPE of APPLICATION n <br /> N ZIP CODE a <br /> T [[TY ENVIRONME�I7ALHEi�Lf �tt=' �..., � �� I (Closure, installation, etc.) <br /> TOTAL <br /> 1486 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, <br /> 1991) = $100.00 S <br /> AS <br /> C licable) XXXX XXXX <br /> T FACILITY PENALTY FEES ASSESSED (if App <br /> I 5170/TANK (After January 1, 1991) <br /> Y TANK FEE = 550.00/TANK (Prior to January 1,1991) <br /> E 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 199b <br /> Tanks = $ <br /> F (multiply # by fee for <br /> A each year applicable) S <br /> C (DI TANK PENALTY FEES ASSESSED XXXX XXXX <br /> L <br /> [ STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T 1986 through 1990 1941 through 1995 <br /> Y # Tanks x 556.00 S <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s)? <br /> L # TANK{s) <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /> STANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> RX 3234.00 = S <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimun/TANK) # TANK(s) <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #{s) <br /> L <br /> A5624.00 minimum S <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) <br /> R REPAIR FEE (Workplan Review & Construction Inspect+ans) <br /> TANK I.D. #(s) <br /> EX $234.00 = S <br /> P TAAK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) <br /> AS <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum <br /> R = 5234.00 minimum S <br /> PIPING REPAIR FEE = 578.00fhour (3 hours minimum/FACILlTY) <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br /> $ <br /> I <br /> S = 578.00/hr � - - <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE ",$— <br /> C <br /> ` <br /> TOTAL DUE S <br /> i <br /> FOR OFFICE USE ONLY <br /> ------PS # COMPUTER CODE DIST CODE AMOUNT RECEIVED_ CHECK #/CASH RECEIVED BY DATE RECEIVED M^ <br /> SWEE <br /> -• 5 <br /> EH 23 032 (REVISED 11-1-92) Page 11 �)� <br />