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- ky <br /> SAN JCACUIN r7JNTY PUBLIC HEALTH SERVICES <br /> EVVIRCMENTAL HEALTH DIYISICN ) { <br /> UNDERGRaJUD STCRAC'c TANX )RCGRAM - FEE UG7XSHEET <br /> FAC:L:TT SITE NAME FACILITY CCNiACT MANE <br /> ! FACILITY A0011ESS '-" SITE PHONE 9 with AREA CXE <br /> L 7V/ S- 707 - 1 ss fo 3 <br /> i — <br /> C:TT / S�V'TAT^E I ZIP CCOE s of TANKS' L,<G +Z� 7 5, ;L at SITE <br /> A I APPLICANT/BILLING NAME APPLICANT =TACT MANE rN1 D '! <br /> ) V <br /> ��— <br /> L <br /> I NAILING ADDRESS APPL!G:NT )HCNE : WITH AREA CCDE <br /> 3ss -yo 3i <br /> N I C:TT STATE "P CCOE PLICAT ICN <br /> C., <br /> /LJ �, n Ga- I �IY5 CI �'^stf:, Zv+s;uLA la, eta Cos <br /> TOTAL <br /> A 1986 119x7 I 19M17989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) • $100.00 <br /> I /ODt/UU OGI: � ' IdGCi S .�r� <br /> v i <br /> a ;ANX FEE • S50.MiTANX (prior to January 1,1991) S170/TANK (after January 1, 1991) <br /> F J ;arks = / 1986 11%7 11988 'iI 1%9 17990 1991 11992 11943 17994 11995 7996 <br /> Al each year S Sy fee for it I` J <br /> each year applicable) �GJ OU /OV,3y�T 3Nc�- ^ I I S i�%rrf0 c= <br /> STATE SLRCNARGE • 556.90 each TANK (Due every 5 years) See California N L S Cade, Section 25287 <br /> 2 ;ants X S56 CO 1986 through 1990 1991 through 1996 <br /> T (enter arrant and year) <br /> SCJ 0-!4 SCJ i I 3- <br /> ^ I PEi.W1NENT CLCS)RE (Removal or AYthorited Closure-in-Place) I TANK I.D. 5(s) <br /> L C.CSAE FEE • S53.CC per hour (3 hours miniasae per TMX) I s TAMK(s)_ X 5159.00 • S <br /> 0 <br /> S <br /> U TEMPCJtMY CLCZURE (A ors-time permit, for review/inpectiene) TANK I.D. Us) <br /> R <br /> TEMPOWY CLCSAE FEE • S150.00 each TANK 0 TMX(s) X 5150.00 • S <br /> PPLAN CHECK K (Install. Plan Review L Con:nuc:ion Inspections) I TMK I.D. t(s) <br /> l <br /> A <br /> H PLAN CHECK FEE - $53.00 per hour (8 haus minim per Facility) • S424.00 minim S <br /> R I REPAIR FEE (workplan review L construction inspection) ( TMX I.D. $(a) <br /> P TAXK REPAIR FEE • $53.00 per hour (3 hours minima/TANX) I f TANK(s) _ X $159.00 • S <br /> A <br /> I <br /> R PIPING REPAIR FEE • S53.00 per hour (3 hour minima per facility • S159.00) S <br /> N TRA%SFER FEE • S20.00 I UNAUTHCRIZED RELEASE EVALUATICU • 553.00/hr I I S <br /> I <br /> S 1 <br /> C =SULTATICM FEE • $53.00/hr I ISANPLIMG INSPECTION F= • 553.00/hr I I 5 <br /> TOTAL DUE , <br /> CFFICE USE CULT <br /> i�„,RTl�sa�'}�<Rs i��}�Je�lf\••1{.ali�l(]�OaJw si�m)�e'I���AOji}oR.�llias�i�(.1�J•.�•lYl`J�a! <br /> e C10 i I yr UIC4 j I IN bWC I 1)1 WC I ML..III 1{[� 11.AC1.A a/W11 I KI.C{Y.-.J al I VAI' M1LLC:VC% : <br /> �srfLr na�Nry oi_ '�3 15 ___ I I _ _____________; <br /> =- �====1=== ------ ------ ------- <br /> lt�i�i�i>•ii/i/>fi!•�i�fisi!•1••i�iaa i�•ii�i>s��ti�ilsii�t(♦�ii�ia•� <br />