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SAN JOAL. ` TY PUBLIC HEALTH SERVICES - ENVIRONMI LTH DIVISION <br /> -GROUND STORAGE TANK PROGRAM - FEE WORT — <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I <br /> T <br /> E FACILITY ADDRESS - SITE PHONE # with AREA CODE <br /> CITY STATE ZIP CODE # of TANKS <br /> A � - �_- G7_ -fic�'„\ �.�, c�J�(t�� at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L � I,t <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> 7 CITY STATE 21P CODE TYPE of APPLICATION <br /> (Closure, Installation, 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 5 XXxxxxxxxXxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx XXXX %XXX xxxx %XXX E XXXX%XXXxxxxx <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = _ 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) xxxx XX%% XX%K %%XX XxXX E <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx xxxx xxxx XXXXS <br /> L / <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 ISO Nyp 8 <br /> T <br /> Y # Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> / l; 6� :y $ 3 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = E <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK 1_D. #(s) PAYMENT <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 mini mum RIECIEqUED <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) L,L,uiVTY <br /> L <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = <br /> $624.00 minimum ENVIRONMENTAL ILTHOIVi$ION <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(&) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum E <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 5 <br /> 1 <br /> 5 <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = 578.00/hr E <br /> TOTAL DUE E j <br /> FOR OFFICE USE ONLY <br /> - ::-: ::::..—:::::::::::::,::-:::-::::::::::::::::::::::::..............,,.............:::: __::-,:..,...,,_.........._........,.;.;........:-:::......::�.........................................:::::_. - - .. - _— <br /> ................ <br /> ::::::::: :::::::::: ::::•••••...ir:!i:....:..1_it nn....:::::::..:::::: ::::..:..................._.............._._.:i :tit: ::::_::..._.....:..........:::.:i.nnu:lim^#/eii:i:iiiiieiiiei�i:e:ieeieei:_C--1c3e�i:isiseiieFi�eeeiii::ei::ei�:::iiiicT uc.^.Ili3i':fii'.fi:liiii:F::::ieiii:ii <br /> i SWEEPS 4 C014PUTE# AL LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED F <br /> "763 -- -- - ; <br /> ......................... ..:::.::::..:_::::::_:::..:.:._::.............. ..............._...._......:........._......... ....___........_ ,:: :::::::::::.._.__............. ..._:_::::-....,_........:..::::........ <br /> :.....................4 t:._.............._............................. ............_.._................... ........:i.............._................._...._..---........._...1....... ._ .:. ..............................._...............:.:............. <br /> :::.:.:..::::_,........................ ..................._.............., ::1:..::::.:::..:::-:::.:::-:::::: _:::_::::_-::::::.:::::.:::::.:::_:.......::__........:_... .......... ............ .._ <br /> ..........,...:::..__. ...................... ..............__:...:.:,::::.:::::. ....::......:...::....:...:....:.....1.:..,... .. . .. .....:.....:...._................._..._:.a::.n,cF ':::::cea;i�—eiii:::::i:::: �:_::::::!iii-:iii:F:FF:iei�:isi::::ii::::::c:e:ee:_u •_.]ii:li <br />