Laserfiche WebLink
SAM JOAOUIM CLIC HEALTH SERVICES - ENVIRCNMENTAL H ION <br /> U. STORAGE TANK PROGRAM - FEE WORKSHEET <br /> TI FAC ILI Y SITE NAME [� I F2 LITY CCMpCj NAME <br /> due k 11^ i/ ex— <br /> E FACILITY ADORES6 SITE PHONE Al with AREA CdOE <br /> CITY STATE ZIP CODE 0 of TANKS <br /> Aat SITE <br /> P <br /> P APPLICA9T/3ILL k4G NAME c 7 APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILf G ADDRESS APPLICANT PHONE s WITH AREA C E <br /> w -' J. 13, U70 _S3o t <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 11988 11989 11990 <br /> CI ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 x= I XXXX / I/ <br /> (fQ dD f <br /> TFACILITY PENALTY FEES ASS'c55'cD (If Applitabla) I XXXX I XXXX >oyO I 0 UD S 'ZpJl7 <br /> I <br /> V TANK FEE s50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> *ranks = �� 1986 ( 1987 1988 ( 1989 11990 11991 11992 11993 ( 1994 1995 11996 <br /> F (multiply s ry fee far fir,., <br /> A each year applicable) XXXX I XXXX r- f I3 (J I3M I/Vw 11020 �/p7') I I 53tj6 <br /> C' v <br /> 11 <br /> l TANK PENALTY FEES ASSESSED XXXX XXXX I jdD 3dn /11Z0I f 07-0 I��' ZU I 1-7 f 3(, 6 C) <br /> Li <br /> 11 STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California N S S Code, Section 25287 <br /> T' <br /> Y <br /> $ Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> 33.6 .33.6 1 $ <br /> Cl PERMANENT CLOSURE (Removal or Authorized Clasure-in-P(ace) I TANK I.D. s(s) <br /> L' <br /> SI CLOSURE FEE - 578.00/hour (3 'nours minimm/TANK) s TANK(s) X 2234.00 <br /> U TEMPORARY CLOSURE (Plan Review 3 Inspections) TANK I.O. s(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) 5234.00 minimum S <br /> Li INSTALLATION ?LAN CHECK (Plan Review d Construction Insoections)I TANK 1.0, s(s) <br /> A <br /> N PLAN CHECK FES = 578.00/hour IS hours minimum/FACILITY) = 3624.00 minimum f <br /> 21 REPAIR FEE (Workplan Review 3 Construction Inspections) I TANK I.D. s(s) <br /> P TANK LINING REPAIR F'<E = 578,00/hour (3 hours minimuNTANK) s TANKS) X 5234.00 S <br /> A <br /> ITANK RETROFIT REPAIR FEE = 5$.JO/hour (3 hours min./FACILITY) = 3234.00 .minimum 2 <br /> R <br /> ?(PING REPAIR FEE = 578.00/hour (3 hours minimnVFACILITY) = Sn4.00 minimum 5 <br /> MI TRANSFER FES = 520.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr $ <br /> II <br /> Cl CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE - 578.00/hr 2 <br /> TOTAL DUE S 6 <br /> FOR OFFICE USE ONLY <br /> SWEEPS 7EPs LOC •:OOE )(ST CODE AMOUNT RECEIVED CHECK -/CASH RECEIVED 3Y I DATE RECEIVED <br /> S . j <br /> EH 23 032 (REVISED 10-28.93) • • <br />