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SAN JOADUIM CCLMtY PUBLIC HEALTH SERVICES - ENVIRONMENTAL NEA'TH DIVSION <br /> U11 20lOO STORAGE TAMIL PROGRAM - FEE WCRKSLEE <br /> S FACILITY SITE AME FACILITY CONTACT NAME in , <br /> T SITE PHONE 0 with AREA CODE <br /> E FACILITY ADD <br /> f I RESS bintm Lp <br /> CITY STAT Z/ICj,Wo CODE of at SITE A l/Fi 'iI:J JU! <br /> P APPLICANT/BILLING NAME APPLICANT ONTACT NAME <br /> L Sammi 45 Qb IVB Qm a � <br /> 1 <br /> C MAILING ADDRESS APPLICANT PHONE A WITH AREA CODE <br /> A <br /> M <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) el <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 2 <br /> A xxxx xxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX xxxx $ <br /> I <br /> V TANK FEE _ (50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> I Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply 0 by fee for <br /> A each year applicabLe) xxxx xxxx f <br /> C <br /> 1 TANK PENALTY FEES ASSESSED xxxx xxxx S <br /> L <br /> I STATE SURCHARGE - 556.00 each TANK (Due every 5 years) See CaLifornla H d S Code, Section 25287 <br /> T <br /> T K Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter asxent and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-)n-Place) TANK I.D. Y(a) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) 0 TANK(s)1_ X 2234.00 = 2 lf,�jp <br /> S <br /> U TEMPORARY CLOSURE (Plan Review d Inspections) TANK I.D. R(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ !78.00/hour (3 hours minimm/TANK) N TANK(s) X $234.00 = f <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. M(s) <br /> L <br /> A <br /> N PLAN CHECK FEE _ (78.00/hour (8 hours minimus/FACILITY) _ $624.00 minimae t <br /> R REPAIR FEE (Workplan Review d Construction inspections) TANK I.D. N(s) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimm/TANK) Y TANK(s) X (234.00 t <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) _ (234.00 minisam T <br /> R <br /> PIPING REPAIR FEE _ 278.00/hour (3 hours minimum/FACILITY) = 5234.00 minisxm t <br /> M TRANSFER FEE = 220.00 UNAUTHORIZED RELEASE EVALUATION = f78.00/hr t <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr t <br /> TOTAL DUE f�3lf,�G <br /> FOR OFFICE USE ONLY <br /> .. .._..____.._ _. _..._....._...._........_- ...:—.—:,,o„- .—_.._.. ._......... .::::.,- .._�-__�- <br /> ...0m. ___.._-_—:::::.__. :::: <br /> ::::::::_ :_ <br /> r::_ _:___:::�_._.:___ �.... :.�;__.:_:::,_.:_::__-:-:_.,....:__:.:_::.::.::_..:._ [ —__ <br /> � SWEEPS a COMPUTER N I LOC CODE DIST CODE AMOUNT RECEIVED CHECK H/CASH RECEIVED BY DATE RECEIVED a <br /> f <br /> .....: ........ <br /> EH 23 032 (REVISED 6-21-93) Page 11 <br />