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UNDERGROUND STORAGE TANK P - FEE WORKSHEET <br />FACILITY SITE NAME <br />FACILITY CONTA ME <br />s o <br />ova �c. S ►d v <br />E <br />FACILITY ADORES / <br />SITE PHONE # with AREA CODE <br />0 <br />93 <br />& <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />SITE <br />AS <br />O C A6 12 <br />I <br />at oZ <br />P <br />PAPPLICANT <br />BILLING NAME <br />APPLICANT CONTACT NAME <br />LC <br />e -e / C <br />Y <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />8 Y3 9j <br />A/ <br />T <br />CITY11 <br />STATE <br />ZIP CODE <br />TYPE of APP <br />GUL'ST Jr G <br />Cid <br />56 <br />(Closure, Instaltation etc.) <br />TOTAL <br />1986 1987 1988 1989 1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />A XXXX XXXX XXXX XXXX XXXX S XXXXXXXXXXXXX <br />C <br />T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX )XXX XXXX S XXXXXXXXXXXXX <br />I <br />V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br />E <br /># Tanks = A/ 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 ® g� <br />F (multiply # by fee for CCl <br />A each year applicable) XXXX XXXX XXXX XXXX XXXX S 40 <br />/ <br />C <br />I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX S <br />L <br />I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T <br />Y # Tanks x $56.00 1988 through 1990 1991 through 1996 <br />(Enter amount and year)®� <br />S <br />CPERMANENT <br />CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. #(s) <br />TANK I.D. #(s) <br />L <br />CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE ='578.00/hr S <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = <br />S <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/fACILITY} = 5624.00 minimum <br />S G <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br />I <br />R <br />= $234.00 minimum S <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) $234.00 minimum <br />S <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />S <br />C <br />CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE ='578.00/hr S <br />L <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/fACILITY} = 5624.00 minimum <br />S G <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />S <br />C <br />CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE ='578.00/hr S <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X S234.00 = S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />= $234.00 minimum S <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum S <br />M <br />TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br />I <br />S <br />C <br />CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE ='578.00/hr S <br />TOTAL DUE L/2 <br />FOR OFFICE USE ONLY <br />