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SAM IC NTY PUBLIC HEALTH SERVICES - E}IVIR TH DIVISION <br /> QGRCUNO STORAGE TANK PRt}I - FEE tiIORKS <br /> S FAC LITY SITE HAKE / f � � � FACILITY CI3 ACT AYE <br /> ih <br /> E FACILITY AOORESS SITE PHONE Rt with AREA =E <br /> A CITY ��L) ��/ / C/-�-I z 'CODe b x of TANKS <br /> I/\A <br /> at SITE <br /> P - <br /> P AP'PL.ICANT/BILLING ,NAME APPLICANT CONTACT NAME <br /> L <br /> I I APPLICANT PHONE 0 WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N I �'`'f -C frees <br /> T CITY � <br /> STATEI ZIP CODE I TYPE of APPLICATION <br /> (Closure, Installarion, etc.) <br /> TOTAL <br /> 1485 1987 11988 11989 � 1990 <br /> ANNUAL FACILITY FE_ (Prior to January 1, 1991) = 5100.00 <br /> A xxxx xxxx 4 xxxx I xxxx xxxx s XXXXXxxxxxxxX <br /> CI XXXX XXXX xXXX XXXX XXXX 5 XXXXXXXXXXXXX <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> Y TANK FEE = 550.00/TANK (prior .a January 1,19913 5170/TANK (o#ter January 1, 1991) =�� <br /> E - ! <br /> Tanks J_. 1986 11987 11988 1989 11990 7491 1942 /1993 I1149�41 1945 1 117 <br /> 995 <br /> F each <br /> eiply = pL fee for I I � ll y� �( V I �� S <br /> A each year applicable) XXXX XXXX XXX% xX%X XXX% ! ! t <br /> C I , " �I ! 0 1 D 7o 17a f ro <br /> I TANK PENALTY FEES ASSESSED I xXXX I XXXX I XXXX I XXXX XXXX i _ <br /> L <br /> ! STATE SURCHARGE = 556.00 each TANK Ode ve ears3 See California N b 5 Cade`, Sec:i.an 25287 <br /> Y I Tanksx 556.00 <br /> (Enter amount and year) . S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. x(S) <br /> L4 TANKWs X $734.00 <br /> 0 CLOSURE FEE = 578-00/hour (3 hours minimum/TANK) <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & inspections I TANK [.0. �(s) <br /> R <br /> E TEMPORARY CLOSURE <br /> --EE--EE = 578.001hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK [.3. 9(s) <br /> L <br /> A S <br /> K PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5524.D0 minimum <br /> R REPAIR FEE (llorkplan Review & Construction Inspections) I TANK E.D. 4(s) <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK} I $ TANK(s} <br /> X 5234.60 = S <br /> AS <br /> I TANK RETROFIT REPAIR FEE = 578.001hour (3 hours min./FACILITY} = $234.00 minimum <br /> R <br /> PIPING REPAIR FEE = 578.O0/hour (3 hours minimum/FACILITY) s234,00 minimum S <br /> M TRANSFcR FE= = $20.00 I I UNAUTHORIZED RELEASE: c'VALUATION = 578.00/hr I I 3 <br /> I <br /> S S <br /> C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.001hr <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> SWEEPSY I�CC,MPUTER i LOC CODE OIST CCQE�I AMOUNTRECEIVEDCHECK ;*/GASH I� RECEIVE�l 3Y I OAT"c RECEIVED <br /> coo <br /> ... <br />