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SAN JOAODIN COLDITT PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />U)A10UND STORAGE TANK PROCJiNI - FEE wORKSHEET- <br />P <br />FACILI TT SIT NAME <br />FACILITY CONTACT NNIS <br />E <br />P <br />TANK REPAIR FEE • 153.00 per her (3 hours minIWTANK) <br />! TANK(s) _ X 5159.00 • <br />L <br />A <br />A <br />H <br />C <br />I <br />FACILITY ADDRESS <br />917E PHONE IF 1NIth AREA (ODE <br />L <br />32o S. Srcr�<Tov �7 <br />Zm9 X99 s�zb� <br />I <br />I <br />CITY O/v�N <br />STATE <br />ZIP CODE <br />! of TANKS Z <br />e <br />�S?�6 <br />■t SITE <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME , <br />P <br />5�/7)LO <br />i/iCd1'Y�PI� �7�9�r1lLro�v <br />v <br />I <br />NAILING ADDRESS <br />V31 C✓, /7/,77Ly �a�9D <br />APPLICANT PHONE / WITH AREA CODE <br />2 oy s2f� 96 S3 <br />C <br />A <br />M <br />CITY <br />�sO� $'✓•O <br />INS <br />L..�q <br />ZIP CODE s/ <br />TYPE of APPLICATION �!GOSy,G•Q �" <br />CLOSURE, INSTALLATION, ate. <br />T <br />10TAL <br />A <br />C <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />T <br />ANNUAL FACILITY FEE (Prlar to January 1, 1991) a $100.00 <br />1 <br />! <br />V <br />E <br />TANK FEE 550.00/TANK (prior to Jaruery 1,1991) 5170/TANK (after January 1, 1991) <br />F <br />0 Tonka 1986 1987 1988 <br />1989 <br />1990 1991 1992 <br />1993 <br />1994 1995 <br />1996 <br />A <br />(aultlply/ W fee for <br />C <br />each year applleablo) <br />I <br />L <br />STATE SURCHARGE • $56.00 each TANK (Due every 5 year*) See [aliform* H L S Cade, Section 25287 <br />I <br />T <br />0 Tania — x 556.00 <br />1966 through 1990 <br />1991 through 1996 <br />Y <br />(enter errant and year) <br />5 <br />PERMANENT CLOSURE (Reanval or Authorized Cloaure-In-Pled) TANK I.D. !(&) <br />C <br />L <br />CLOSURE FEE • $53.00 per her (3 hours mimeo* per TANK) <br />IF TANK(*) Z— K 5159.00 <br />It 3( S, co <br />0 <br />S <br />U <br />TOMORARY CLOSURE (A ane-tlr permiNt, for review/irlepeatlone) <br />TANK I.D. !(a) <br />R <br />E <br />TENPaURY CL05URE FEE a $150.00 each TANK <br />! TANK(*) _ X 5150.00 <br />5 <br />P <br />PUN CHECK (Install. Plan Review t COrtruetNOl Irspeeti0m) <br />TANK I.D. !U) <br />E <br />P <br />TANK REPAIR FEE • 153.00 per her (3 hours minIWTANK) <br />! TANK(s) _ X 5159.00 • <br />L <br />A <br />A <br />H <br />PLAN CHECK FEE - 553.00 per hour IS hours •Imam per Facility) a 5424.00 ■Ininn <br />5 <br />R <br />REPAIR FEE (workplan review i cormtructlan inpaetims) <br />TANK I.D. !(e) <br />E <br />P <br />TANK REPAIR FEE • 153.00 per her (3 hours minIWTANK) <br />! TANK(s) _ X 5159.00 • <br />! <br />A <br />I <br />R <br />PIPING REPAIR FEE • 153.00 per hour (3 hour ■Inlaaa per facility a 1159.00) <br />1 <br />N TRANSFER FEE a 120.00 <br />I <br />S <br />C CONSULTATION FEE a 153.00/hr <br />OFFICE USE ONLY <br />UUUTHQIZED RELEASE EVALUATION a 553.00/hr <br />SAIIPLINO INSPECTION FEE a 253.00/hr <br />1 3/8.00 <br />� •• w+� ^ new rrAealwlwlwewrarrraearMwawwwlswaeewlw�wawwralgw <br />IN 73 OY7 (REV 4/8/91) ft Paas 11 <br />5 <br />TOTAL DILE <br />