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+ <br /> JAN JUAGUIH CMINTY PUBLIC: IMALIN SERVICES — ltXVH=MXIAL HEALTH DIVISION <br /> UNDEp--I D STORAGE TANK PROGRAM - EEE WORKSHEET <br /> S fACILITY,SITE NAME FACILITY CONYAL._ <br /> I . ` == k t ) <br /> E FACILITY ADDRESS ��®� � • `�����_� ®��� SITE PHONE # with AREA COOS <br /> & iT 1 (. 95-7 <br /> CITY STATE ZIP CODE # of TANKS, <br /> A at SIVE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME 9 <br /> L - 'L' lil�a �-0 lo <br /> 1. <br /> I <br /> C MAILING ADORES �q APPLICANT PHONE # WITH AREA CODE <br /> N 60 Wil A�%v •�L-�`i' �� .:�� —�IOC3 <br /> T CITY STATE ZIP CODE PYPE of APPLICATION <br /> Mui•. to ( .PA ,�5�ZS' Clasure, Insta�tlatio�, etc.)a <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX Mom XXXX 5 ===00= <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX )0= XXXX XXXX XXXX S xxxxxxxxxxxxx <br /> I <br /> V TANK F£E.= S50.00/TANK (Prior to January 1,1991) S170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 199f 1994 1995 1996 <br /> F (muttipty # by fee for <br /> A each year applicable) )0= X)= X)= )0= . X000 S <br /> C <br /> I TANK PENALTY FEES ASSESSED. - )0= AD= •X000 XXXX XXXX <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25287 <br /> T <br /> Y # Tanks x S56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removat or Authorized Ctosure-in-Ptace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimCwTANK) # TANK(s) X S234.00 .= 5 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 3 Inspections) TANK B.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour.0 hours minimuWFACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review 6 Construction Inspections) TANK.I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 haus minimum/FACILITY) = S624.00 minimum Y, 1.5MCI. S 36.00 <br /> R REPAIR FEE (Workplan Review 6 Construction Inspections) TANK.I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/haw (3 hours minimum/TANK) # TANK(s) ' X 5234.00 a S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 haus min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minim= S <br /> N TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION =S78.00/hr S <br /> I <br /> C CONSULTATION FEE = 578.00/•hr SAMPLING_INSPECT IOU-FEE 5.78.00/hr - a, : ,t r: S <br /> TOTAL DUE S <br /> FOR OFFICE USE CULT <br /> SWE£PS # COMPUTER 0 LOC';CODE. 01 ST.CODE: AMOUNT RECEIVED CHECK #/CASHRECEIVED BY-.�. „' DATL'it/CASHREC2IVW,.* , <br />