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-3Aa-"so=IM COUV y PMIC hi:AL7i1 ScAVICES - ENVIRDUWXTAL BEALTH VIVIs ov <br />AM UdDER=OUNC STCsuGB TAwt PRC=A* - FE>WftCSHEjET <br />uTT SITE NAH <br />�L e SW <br />CONTACT NAME <br />FC I CILIT7 AOORESS <br />CAFMA...� <br />aNNual FACILITY FEE (Prior to laruury j� `s� <br />Q4j;.oD <br />SITE PWW S® with AREA =9 <br />e s/ <br />L .Z (7 Z. LA,J �fg/hi�ifi� L• !v <br />1986 1989 <br />` 1940 <br />ZOg 7.i�! Z /®® <br />CITY <br />A 5 'TOd <br />py�y <br />sTA71; <br />GA <br />ZIP CwE <br />S.2 O 9 <br />It of TANKS <br />at SITE <br />P <br />T <br />1 <br />FACILITY PENALry Pegs uSes5E9 of <br />==tt 322z <br />XXXX <br />X)= <br />P APPLICANT/BILLING NAME <br />IO(XX <br />S xXXXX x=x <br />APPLICANT CONTACT NAME <br />I—T-9IAN6,LE GNVIR®NM6TA.L.. <br />tN L <br />IS7-61/ef <br />R0atA9*A/ <br />C MAILING ADDRESS <br />s <br />APPLICANT PHONE 0 YITN AREA CODE <br />�" ZS2$' W Qy1�6�►a)k J3C.tJA <br />1 1996 <br />g�$ $'Li0 700 <br />T CITY L <br />du 2aAN k <br />s� <br />YTATII <br />C A <br />ZIP COD$ <br />is® r; <br />T1'Pt of APPLICATTON R t+P03P I& <br />(Ctosura. Instattacion, etc_) <br />F (Multiply S by fee for UHVICFq <br />A each year applfcabte) XXXX xXXX x]c70(''� 'XX)0I 1 <br />C 1 <br />: TAXK PSMALTY ;-=ES ASSESSES) I XXXX I )(XXX mcX I xy-u XXSy( <br />L 1 <br />I SATE SUBCMARGe ' 06.00 each TAMC (Dun every 5 rears) See California N T► S Code, Sac -don 25287 <br />T <br />T N Tanks x 356.00 1988 through 1990 1991 through 1996 <br />(Enter amount and your) <br />--C PERMANENT m (R a( Or Authorized Closure-fn-P(acs}. TANK I.Oe S(s) <br />i. L <br />0 CLOSURE FE9 a S78.00/hour (3 hours miniauo/TANK) S TANC(s) X SZTG.00 : <br />s <br />U TEMPORARY CLOSURE (Pian Revive & Insneotioetis) 'AMC. I.O. *Cs) <br />R <br />El TIMPORART CLOSURE FEE a 378.00/1hour (3 houra Minimum/FACILITY) So&.= sinim m <br />CAFMA...� <br />aNNual FACILITY FEE (Prior to laruury j� `s� <br />Q4j;.oD <br />19% <br />1987 <br />1986 1989 <br />` 1940 <br />S XAAA/.MMA <br />�yyy <br />py�y <br />yyy�/ �/y�/ <br />/OMP M/1^A� <br />yy�y- <br />eolr/� <br />ARM <br />T <br />1 <br />FACILITY PENALry Pegs uSes5E9 of <br />==tt 322z <br />XXXX <br />X)= <br />XXXX XXXX. <br />IO(XX <br />S xXXXX x=x <br />E <br />V <br />3 <br />TANK FEE A S50.00/TANK (Prior to January 1,1991) <br />S170/TANK (AfTer January 1, 1991) <br />TANX LININO.REPAIR PEI a 3719.00/hour (3 hours mintaun/TAaC) S TANK(s) X 2236.00. <br />s <br />x Tanks a 1986 "89 ` 1990 <br />1991 1 1992 1 1993 11994 11995 <br />1 1996 <br />F (Multiply S by fee for UHVICFq <br />A each year applfcabte) XXXX xXXX x]c70(''� 'XX)0I 1 <br />C 1 <br />: TAXK PSMALTY ;-=ES ASSESSES) I XXXX I )(XXX mcX I xy-u XXSy( <br />L 1 <br />I SATE SUBCMARGe ' 06.00 each TAMC (Dun every 5 rears) See California N T► S Code, Sac -don 25287 <br />T <br />T N Tanks x 356.00 1988 through 1990 1991 through 1996 <br />(Enter amount and your) <br />--C PERMANENT m (R a( Or Authorized Closure-fn-P(acs}. TANK I.Oe S(s) <br />i. L <br />0 CLOSURE FE9 a S78.00/hour (3 hours miniauo/TANK) S TANC(s) X SZTG.00 : <br />s <br />U TEMPORARY CLOSURE (Pian Revive & Insneotioetis) 'AMC. I.O. *Cs) <br />R <br />El TIMPORART CLOSURE FEE a 378.00/1hour (3 houra Minimum/FACILITY) So&.= sinim m <br />Pi <br />L <br />INSTALLATION PLAN CHSCX (Pian teview & Construction Inspsc:Sons) TARN; I.D. s(s) <br />A <br />y <br />PLAN CHECX FEE a 578.00/hour (8 hours limimww/FAr.IL;TT)-.--UZ4.00 .ainimLae <br />t <br />R <br />REPAIR f£E (YortPtan Review.L Construc cion Inspectimm) ` TANIL"I.D. Ks) <br />E <br />_- <br />P� <br />TANX LININO.REPAIR PEI a 3719.00/hour (3 hours mintaun/TAaC) S TANK(s) X 2236.00. <br />s <br />A <br />I <br />XTAWK RgTROFIT REPAIR FE=- s 979,00/hour C3 hours min./FACILITT) a 204.40 ariniawin <br />s� <br />R <br />PIPING QS;PAIR PEE a S78.00/hour (3 hours ainimunlFACILITT) a 2234.00 aainimsam <br />S <br />i <br />11 <br />TZANSF-cR FIE 220.00- ( UNAUTN0R12ED R@LEAS$ ZVALUATION ;=®'i7$r00/kP <br />2 <br />I <br />C <br />CONSULTATION PRE 2 578.00/hr SAMPLING tNSP$t;I01t F2g. : s 978.00Ar. P <br />s - <br />:_ TCMu <br />' FCR OFFICE USE ONLY ... ' •` Y' <br />- Nom= <br />SWEEPS 3 C14 --ER s LCC CODE hES; C7D6 AM(ZS:NT itEiEIVEIs, '-CIIECL 8/CJtSNj REC8IVE0 BY + GATE RELIVED <br />1. <br />-. .. - .. <br />_ <br />• .uuw.�r.-..a _m-ra^iw-pp'�gl�y 11WLL'P"F S�i�tl+t34i <br />H. <br />