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` SAM JMMTY PUBLIC HEALTH <br /> SERVICES - EMVIRGppR <br /> S FACILITY SITE HAMS <br /> ERGRCUNO STORAGE TANK PROGRAM _ FEE �RKSH TH DIVISIOM <br /> I 'J / FACILITY T FA <br /> �l COHTAC7 HAMS <br /> E FACILITY ADDRESS i) y <br /> r} SITE PHONE S with AREA CODE <br /> CITY <br /> A <br /> P TATEI ZIP CODE <br /> � X at TANKS / <br /> P APPLIGNT/BILLING NAME at SITE <br /> I I APPLI CANT <br /> CONTACT NAME <br /> C NAILING ADDRESS <br /> A I APPLICANT PHONE X WITH AREA CODE r'nat� ('. <br /> �+'G <br /> N <br /> T CITY a-LUGG <br /> STA7EI ZIP CODE I (CP�Of APPLi cArrom <br /> atlacion, etc.) <br /> ANNUAL FACILITY FEE (Prior cc Janus TOTAL <br /> A �^/ 1, 1991) = 5100_00 1986 1987 11988 11989 1990 <br /> C <br /> xxxx xxxx I I FACILITY PENALTY FEES ASSESSED I XXXX I XXXX I X)(XX 5 XXXXXXXXXXXXX <br /> T <br /> [ (If Applicahl e) <br /> V TANK FEE = 550.00/TANK (Prior <br /> I XXXX I XXXX I XXX% I XXXX I XXXX S XXXXXXXXXXXXX <br /> or Co <br /> E (PriJanuary 7,1991) <br /> 517(1/TANK (Atter January 1, 1991) <br /> Y Tanks = 1986 1987 1988 11989 11990 1991 11992 11993 11994 17995 I 1996 <br /> F (multi ply s by fee far I I <br /> A each year appticahte) <br /> C xxxx I XXXX I XXXX I XXXX XXXX ) -7 <br /> I TANK PENALTY FEES ASSESSED I XXXX xxxx I XXXX I I xxxx %XXX <br /> L C <br /> I STATE SURCHARGE = 556.00 each TANK _ S <br /> T (Due Avery $ years) See California H ; S Code, Sect' <br /> T ianks� x 556.00 1°^ 25287 <br /> (Enter amount and year) 1988 chr°ugh 1990 <br /> 1991 Through 1996 <br /> S(o oCJ <br /> C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) <br /> L I iANK L0. g(s)0 CLOSURE FEE = 578.00/hour (3 hours �ninimAn/TANK) <br /> S I x TANKCs)__ X 5234.00 = <br /> U TEMPORARY CLOSURE (P tan Review ; Ins S <br /> R pectionS) I TANK I.C. :(s) <br /> E TEMPORARY CLOSURE FEE = 578.30/hour (3 hours minimum/FACILITY <br /> 5234.00 minimum <br /> i <br /> PI INSTALLATION PLAN CHECK (Plan <br /> L .Review 3 C°nSIrU°Lion Inspectjons)I TANK LD. :(s) <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours mini mtm/FACILITY) <br /> 5624.30 minimi i <br /> ' REPAIR FEE (Workplan Review 3 Canszruction Inspeo-joss) <br /> E TANK I.O. H(s) <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /> A i TANK(s) __ X 5234.00 = <br /> I TANK RETROFIT REPAIR FEE S <br /> R vt?r = 578.00/hour (3 hours min./FACILITY) <br /> = 5234.00 minimum 5 <br /> ,vc REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) <br /> = 5234.00 minimum I i <br /> M+ TRANSFER FEE = 520.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br /> S <br /> I I S <br /> I I <br /> CQNSULTATICN FEE = 578.00/hr <br /> Cl� SAMPLING INSPECTION FEE = 57$.00/hr I I I <br /> .._"i aC USE <br /> FOR OFFICETOTAL DUE s <br /> ONLY <br /> SWEEPS 3 I COMPUTER I LOC CODE DIST CCOE I ANDUNT RECEIVED I CHECK 7/GSH I .. RECEIVED 8Y <br /> i GATE RECEIVED __ <br />