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r <br /> SAN JO QUIN (: . TT PUBLIC HEALTH SERVICES - ENVIRONMENTAL b1 LTM DIVSIOM <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE YORKSHEET <br /> S FACILITY SITE NAME tCODE <br /> ACILITY CONTACT NAME <br /> ' 'DIAM00 WAtWLr 62aW 45 Pf1kw-c UCC.Lstb1 <br /> T <br /> E FACILITY ADDRESS I E PHONE N with AREA CODE <br /> 0GO SoLLTH DIAMorJD Sf. Z0 4/0 - o <br /> CITY N of TANKS 3 A80VG GF-Nb TONICS <br /> A I at SITE 5 DG V' PML <br /> P <br /> P APPLICANT/BILLING NAME PPLICANT CONTACT NAME <br /> L DIAMOND W LAT G LIJIyu hssocMI L-ECLSror) <br /> I <br /> C MIIIIINC ADDRESS PPLICANT PHONE / WITH AREA CODE <br /> " O50 So LLTH D(nrnlot, 6m-Eer9 CITY TYPE of APPLICATION <br /> (Closure, Installation, etc.) C(„OSICR->; <br /> TOTAL <br /> 1986 1987 1988 1989, 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) t100.00 <br /> A L <br /> C <br /> i FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx XXXX S <br /> I <br /> V TANK FEE 150.00/TANK (Prior to January 1,1991) %170/TANK (After January 1, 1991) <br /> E <br /> N Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply !YWfee for <br /> A each year applicable) S <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx t <br /> L <br /> I STATE SURCHARGE • $56.00 each TANK (Due every 5 years) See California H L S Code, Section 25287 <br /> T <br /> T N Tanks x 156.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. N(s) <br /> L <br /> 0 CLOSURE FEE • %78.00/hour (3 hours minimum/TANK) A TANK($) I:i x $234.00 • <br /> S <br /> U TEMPORARY CLOSURE (Plan Review i Inspections) TANK I.D. N(a) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours mi nlmm/TANK) N TANK(a) X 5234.00 • % <br /> P INSTALLATION PLAN CHECK (Plan Review 6 Construction Inspections) TANK I.D. N(a) <br /> L <br /> A <br /> N PLAN CHECK FEE • !78.00/hour (8 hours mini mum/FACILITY) $624.00 minimum RECFJVf <br /> R REPAIR FEE (Workplan Review 6 Construction Inspections) TANK I.D. N(a) <br /> E <br /> P TANK LINING REPAIR FEE = 178.00/hour (3 hours minilnn/TANK) N TANK(s) fUedlCNEALTM SER IBES <br /> A )yfSffip--- <br /> 1 TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) _ 2234.00 minimus 5 � - <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minima/FACILITY) • $234.00 minimum S <br /> MTRANSFER FEE • $20.00 UNAUTHORIZED RELEASE EVALUATION • %78.00/hr S <br /> I ) <br /> S <br /> C CONSULTATION FEE _ %78.00/hr SAMPLING INSPECTION FEE = S78.00/hr f 1 <br /> r i I TOTAL DUE $/ I <br /> FOR OFFICE USE ONLY <br /> amWMRR14, Yl�r!i,ll�Imn�HU1,,MN,i '�II�Nnmlllu NlHmaNl�Piwnnmg gpi�nelA�RNeuipn pnN.:1�i�ImillmmnwN"IIINIIN!"flmNIN"Im.! IIY! NmN <br /> .m. al m. !I.4 111"WHIR. !ii l l!!!IIIh:.N. .Tl!!N! .i a me'.u,Il:Hr!!m NNNILmm!��;I!Ltl:J�i.!.�n!a:mNr;n!n!!.M.i!A!!!n.4mn!nnnl�i'!i�nnnlllN nu! ! ,..ne.!!e!.esm�.NN�;!;!! <br /> SWEEPS N COMPUTER N LOC CODE DIST CODE AMOUNT RECEIVED CIIECK N/CA511 RECEIVED BY DATE RECEIVED <br /> pp fppp qqpp 11pp p1 aaa� p�pmppp pNN ,1 !MaM <br /> &fII <br /> 032 (REVISED 11-1.92) �...ai ?� �.- /Page 1�' r.J <br />