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SSAM JOACAJIMLIC HEALTH SERVICES - ENVIRONMENTAL TN DIVSION UNDERGROUND STORAGE TK PROGRA14 - FEE WORKSHEET S FACILITY SITE NAME FACILITY CONTACT NAME T E FACILITY ADDRESS SUE PHONE # with AREA CODE & --Tu 11. EZ000 --1. 7,01 CITY STATE ZIP CODE # of TANKS A t< C 10 at SITE P P APPLICANT/BILLING NAME APPLICANT CONTACT NAME I I C MAILING ADDRESS ;PPLICA T PHONE # WITH AREA CODE T CITY STATE ZIP CODE TYPE of APPLICATION l (Clos , Installation, etc.) TOTAL 1986 1987 1988 1989, 1990 ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 A $ C T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX $ I V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) E Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1495 1996 F (multiply # by fee for A each year applicable) $ C I TANK PENALTY FEES ASSESSED XXXX XXXX $ L I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 T Y # Tanks x $56.00 1986 through 1990 1991 through 1996 (Enter amount a year) S C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Ptace) TANK I.D. #(s) L 0 CLOSURE FEE = $78.00/hour (3 hours mini /TANK) # TANK(s) X $234.00 = $ S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours mini /TANK) # TANK(s) X $234.00 = $ P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)FTANK I.D. (s) L A N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 mini $ R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. (s) E P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ A I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ R PIPING REPAIR FEE _ $78.00/hour (3 hours mini /FACILITY) = $234.00 minimumg M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ 1 S C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ TOTAL DUE $ FOR OFFICE USE ONLY ««°.s.;. s.;;•.l:•:•:r.:::::r......s:er.•s•t° •ss:•a•s:rs^ c:t.:r^tt::::...;:....:....................�..................,..............................»................................«„.................. as::as..u..:.:..».»....... .....:.i. s...tE..t..?F...tF§F!F..£.£.:£ss§..3..:t.:::•:.:......................:.a......a.«.............i.............. ...................................s......a.:•::.;.....................:....................................°............ ......_...........................° .................................. ^...........»... ......:.......:..........a.....F....«.......,....a........t....:.i.......•s.............«...t.,..,F..a...:....a........a.s.i:...v s.;......;........r.a.s. ....s...s.............».a.a:z:...................a.... .....................::......«i.:a.«..:....s. .:...a:•..........:........a..:...F.........«...........................................................««............,........................... ..t. .k.....t,t,..,........i.t.,.a..:§FsFn....a....»...^^£....s.....:.........:F..t.:.t...t.....t...°....t.t....i..:.m ...,.i...t„.................E.1....«..... i ....i».....f...t......»«,...»..........t.......t.......t......t..ii...:t......t.....................i.:i.........................................:..,..;..........................««.............................................................................................«..«..... ..—IMMs::.B^aa.£»«...i.........ia........................t,,...........................^.....«......« ... .......................................«.«..«.,.......«.. t t ......... t.............»........ i....a......«......».......5....................».........................:....^.: .......«..««................ SWEEPS COMPUTER LOC CODE DIST CODE AMOUNT RECEIVED CHECK /CASH RECEIVED BY DATE RECEIVED £f: ?ilii££?'t£EE.4s.?i:i§!!FFis3N??iiFi::£:%?F7?[FFH332: t:! •::-•••:• «mr: si.•:aa::::�:••u: ••.:•r.^.r••r.»u•:ur••:asa:r•irs:nrs«r:::u:^:n::::m sa.•r. •••••••••»•••.••.... ....... .... »... ..... ..... �i 'E•FFF'Es ifx"46 ..:Sr..t:dzFtse.rs.m.,.u...;.......es.s7tx§uaa:«.nv.....t.t..asFt.., r• .;;.t...... ........«........ .....-•.. .......»... .............. ...i:,.t.....s.n.:.§£«...t...,...»!..iF...u.u£ft.f§.Ei:9ah.:a„S.a ss t.§F..s..R::Fu'4:iF§ii!dsit:.r£aFfrs.ik s::a a;u.: i s••s:•::•i::•s::a•^s:•::•' .. . n t ......a.•r t.: .,...:......a is x...«.a...,s• :................. .. ..........«.......... .._..........:..«.... . s ! .El.a..FFF.!E.iif?s..t..li.t.i.:...&§§..n.s..§d4t ..S. :§..!FFdLs.es?3s.a.kl.Lk�Fis&.t.:..t....«s3.F!...x?F§.:....i.......§s..i...!»«......§..,.dFi!•:§r.::?::a£:.�§s§:::::§FF::?£ti:£r.:�4:::?:•:r:r•••e. .:ai:...t. ...s.:...:...r..:::^:•:r:r::::vr.•••::•»a•::x i.:::r.:^::atrsis••:•:r sa::•:::nt:•,•••••••••.•• •• ' .,»...aFF..1...:..r..t..{:i..F:at......a.........:..:»:..:.......t£tit.,ir...:....t3F§.3.§.....a........«.:n.4:.§.ti...F..f:£a.....i,?:.:nF.i:?i:?:;�cn:§§su:7; EH 23 032 (REVISED 11-1-92) Page 11