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ENTAL <br /> SAN JIN COUNTY PUBLIC HEALTH SERVICES - E- FEE WptKSHRKSH HEALTH DIVSION <br /> JO <br /> INN <br /> STORAGE YANK PROGIIAN FEEEi <br /> _ <br /> FACI IYY CONTACT NAME <br /> ACILITY SITE NAME rE l')sn&5 <br /> t7�oc�-tali r I SITE PHONE 0 with AREA CODE <br /> FACILITY ADORES ZIf4? <br /> 0 d <br /> t STATE 2lP CODE K of TANKS <br /> CITY at SITE <br /> A <br /> P _ APPLIq T CONT T N E <br /> P APPLICANT/BILLING NAME <br /> L APPLICANT PHONE / WITH AREA CODE)A N 14 1993 <br /> C MAILIN DDRESS <br /> N a STATE ZIP CODE TYPE of PPLICATIOtloO I NMENTALHEALT <br /> T CITY \ 2U <br /> o TOTAL <br /> 1966 1987 1988 1989 1990 , <br /> ANNUAL FACILITY FEE (Prior to January 11 1991) • $100.00 f <br /> A ! <br /> xxxx <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> 1991) 1991) <br /> I $170/TANK (After January 1, <br /> V TANK FEE = $50.00/TANK (Prior to January 1, <br /> E 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> M Tanks • __ f <br /> F (multiply M by fee for _ <br /> A each year applicable) 9 <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx _ <br /> L <br /> 1 STATE SURCHARGE • $56.00 each TANK (Due every 5 years) See Californle H L 5 Code, Section 25287 <br /> 1991 through 196 <br /> 9 <br /> I <br /> y x (56.00 1986 through 1990 <br /> p Tanks_ <br /> (Enter amunt end year) <br /> S <br /> TANK I.D. R(a) <br /> C PERMANENT CLOSURE (0.emovel or Authorized Closure-In-place) x $234.00 <br /> s) (' <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) / <br /> S TANK I.D. M(a) <br /> U TEMPORARY CLOSURE (Plan Review L Inspections) <br /> R N TANK(s)__ x $234.00 • f <br /> E TEMPORARY CLOSURE FEE • S78.00/hour (3 hours minimum/TAN <br /> PINSTALLATION PLAN CHECK (Plan Review L Construction Inspections) TANK I-D- M(s) <br /> PAYMENT <br /> L <br /> A9624.00 minimum <br /> N PLAN CHECK FEE . $78.00/hour (8 hours minimm/FACILITY) • ! <br /> TANK I.D. M(s) r' � <br /> R REPAIR FEE (Workplan Review L Construction Inspections) N �DU N ''f Y <br /> E <br /> P TANK LINING REPAIR FEE a 578.00/hour (3 hours minimum/ <br /> N TANK(s —{� NMENTAL HEALTH ��� ' C)IY , ��n <br /> A . $234.00off <br /> I TANK RETROFIT REPAIR FEE • $78.00/hour (3 hours min./FACILITY) $ <br /> R . $234.00 minimum <br /> PIPING REPAIR FEE $78.00/hour (3 hours minimuNfACILITY) <br /> M TRANSFER FEE • !20.00 UNAUTHORIZED RELEASE EVALUATION <br /> • $78.00/hr $ <br /> i f <br /> SSAMPLING INSPECTION FEE • $78.00/hr <br /> C CONSULTATION FEE $78.00/hr TOTAL DUE S <br /> FOR OFFICE USE ONLY a u mmmuu DATE RECEIVED <br /> nrr^m=nmmn;xmmmmxm�m!nnl!m!exrpBwuwmwuuv°u�°�iume!�uu <br /> YBSWE'S <br /> SWEEPS M COMPUTER M LOC CODE DISI CODE AMOI1Ni RECEIVED CHECK CASH RECEIVED BY <br /> // ''// 3 s J3gapJ( ym7/ <br /> e;:!;f:�`nu!"iHuum!mnm mmmr !m iG!mm�mn m u n!amm HIM no ®pu°�!p!!!gw�pmun,ume! n <br /> !r:::!u:muaum!mmmmunv ill so!vummmuw!��m l[itioromI!ii��°uuae°" ! m <br /> Page 11 <br /> �� xc nv rvcylcED 11-1-92) - `' <br />