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'AN JOAOIJIM =MT?—PUBLIC HEILTN SERYIClt . IWVIRCMIENTAL NfALT�yf ip) �S�Z <br /> I1tWERGR(RAID STORAGE TANK PROORUI - FEE UORKSHEET <br /> S FACILITY SITE NAME <br /> 1 ! FACM <br /> ACL NAME/� LSO E! FACIIITT ADORE3$ /- �/ ��� siTrlth MEA Uxa!t / ?oCI1TKV <br /> �A�7�/�/ { sT Tt 2V CODE of TANKSP '\ ITE G..._- <br /> P APPLICAIIT/ULLING NATE <br /> L O APPACT MAJEC NAILING ADORESM UjgQz G� APPLt R ri TN MEA COD!T CITY STA t ZIP CODE APPLICATYdt� •, Irrtall•t lon, ate.) <br /> TOTAL <br /> AAMUAL FACILITY FIT", (Prior to J ruery 1, 1991) 5100.00 1986 19117 1 <br /> A [ry� /� C <br /> C R CE VE 1 <br /> I FACILITY PlluLtt fEE! ASSESSED (if ApplleW— - KK%K R)Dat J N 0 19., .R <br /> I <br /> V TANK It! t30.00RASK (Prior to Jewry 1,1991) 8170/TANK (After JngJpJyJ("911i'llwfY <br /> s teMct • 1906 1907 196E 1989 1990 1991 1992 199 , <br /> F (MA t 1ply Ta/-fee for V1 ilii L DIVISION <br /> A •adt year §Mtlesbts) <br /> C t <br /> I TANK PENALTY FEES ASSESSED 7D0[X XA(X ! <br /> L <br /> I STAT[ BACAMGE a {36.00 each TMK (Due every S years) tee 4ll}ornle N s f Cad•, Section 27287 <br /> t <br /> T ETartu 1 $56.00 1966 through 1990 1991 through 1996 <br /> ([nter ••ant •red year) <br /> 1 <br /> rz $ �/ <br /> C PIWAXENT CLOSURE (R�l or Authorited Char•-In-Placa) TANK I.D. ((Y) <br /> L <br /> 0 CLOSUAI FEE a $78.00/h(lur (3 hoUra •InimUVTANK) 0 TANK(•)_ % t23<.DO . t <br /> I <br /> U TEMPORAAT CWSIRt (Flet Revfw i Irrp•ctlarw) TANK I.D. f(•) <br /> 1 <br /> ( TUVOWT CL03LIN FEE a $78.00/har (3 h*zt NIn1mik/fACILITY) • !234.00 NnIeNUS % <br /> P INSTALLATION PLAN CHECK (Flet Review $ Corr traction (rrpeet ion) TANR I.D. 1(e) <br /> L <br /> A <br /> N PLM CMF_CS .1" a 171.04/feta IS ho:.ri e!nia1VFACI!ITT) a W,4,= r:n1"I <br /> I RtPAII fit (Yortplen teviw i Corstruetion Itrpectlarr) TANK <br /> P TASK LIVING ttPAIR In a 078.00/hour (3 hoer! Nfnitu/tAMK) 1 tANK(t) % 1234.DO . t <br /> A <br /> 1 TANK WTSOFIT REPAIR FIE a 178.00/hoUr (3 hours Nin./FACILITY) a $23[.00 Niniaw s <br /> 1 <br /> PIPING REPAIR FEE • 178.00/har (3 hart Nlnlaa/FACILITY) a ".00 minimum t <br /> N TSAMSFIR Fit a t20.00 lRIAl7f Ntyt7f0 REL/ASE [VALJIATICII • t78.00/1%r 6 <br /> I <br /> f <br /> C COMMTATtON Flt • $78.00/hr !AWLIMG INSPECTION FEE • 278.00/hr 1 <br /> TOTAL. DUE 71777 <br /> rce OFFICE USE ONLY <br /> wi�� '! Jlil WJl � LNE13 I/I.ASN �� � <br /> 1 1/2 - 0_1) <br /> ••�������������.asat.ra Neww..r.�.• .7�r�Ci NN � M�•=ir�Ni•s••�w.�UaUes ��.er <br /> EM ZS 772 (REV1sEo 3-1-93) Pwe 11 <br />