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SAN JOAWIJI CCUNTT PUBLIC HEALTH SERVICES - ENVIRONNENTAL HEALTH DIVISION <br /> Aim STORAGE TANK PROG2AM FEE LORKSHEI <br /> TY <br /> S FACILITY SITE NAME FAC WA <br /> I 5 a- av/ eT - n L L <br /> T SIim PHONE : with AREA CODE <br /> E FACILITY ADDRESS - <br /> & CITE /V is ZIP CODE of TANKS <br /> A dl 9 a a a: SITE <br /> PAPPLICANT/BILLING NAME �1 APPLICANT CONTACT NAME <br /> L DIh _ <br /> I APP !CANT P1(ONE : w[T EA CODE JO`�CQ- <br /> C MAILING ADDRESS ; - J,_ .�1 I� _b6� F" _ <br /> A lJ d�lV J.J 1" <br /> T CITY STA E ZIP CODE TYPE of APPLICATION <br /> lil IG� (Closure, Iretalla:ion, etc_) <br /> �'(l / TOTAL <br /> 1986 1 1987 1 1988 11989 1 1990 <br /> ANNUAL FACILITY F (Prior to J.rn ry 1, 1991) = 5100.00 <br /> A XxxY—In= I )0= I == I X.�CX 5 XXXXXXXXXXXXX <br /> CI XXXX I ( I = I XXXX I XXXX i XX <br /> T FACILITY PENALTY FEES ASSQ—= (If AppLimoLe) <br /> I1991) I 5170/TANK (After January 1, 1991) <br /> V TANK FEE = 550.001TANK (Prior to January 1, <br /> 1991) <br /> Tanks = 1986 11987 11988 7989 11990 17991 11492 11993 199E 1995 11996 <br /> F (multipty = try fee for <br /> Al each year amticaole) XXX:( I )0= axx I XXXX XXXX S <br /> =aXXXX I S <br /> 'ANK PEHALTT FEES ASSESSED XX I )0= XXXX )D= I I I <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Cade, Section 25287 <br /> 7 <br /> T : an z SSd_00 1988 through 1990 1991 through 7996 <br /> (Enter amo=z and year) I S <br /> C� PERMANENT CLOSURE (Removal or Authori Zed CL osure-in-PLace) I TANK I.D. +(s) <br /> LG TANK(s) X SZ4-.00 = S <br /> 0 CLOSURE FEE - 578.00/hour (3 hours minimxLlTtANK) <br /> S ' <br /> Ui TEMPORARY CLOSURE (Plan Review & lnspectionS) TANK I.D. :(5) <br /> R S <br /> EI TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimtAVFACILIIY) SZ31..00 minimum <br /> PI INSTALLATION PLAN CHECK (P(an Review & Cmst:vc=Tan Ireoectiore)I TANK I.D. =(s) <br /> L <br /> AIS <br /> NJ PUN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 56X.00 minimum <br /> RI REPAIR FEE (tlorkolan Review & Const:uCtim Irspec:ims) I TANK I.D. *(s) <br /> ES <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) TANK(s) X 5234..00 = <br /> AS <br /> I TANK RETROF17 REPAIR Fc = 578.00/hour (3 hours min./FACILITY) - 523E_00 minimum <br /> RI S <br /> PIPING REPAIR FE = 578.00/hour (3 hours minima/FACILITY) = SZ3L.00 minimum <br /> MI TRANSFER FEE 520.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I 15 <br /> SS <br /> C CONSULTATION FEE = 578.00/hr I I SAMPLING INSPECTION FEE = 578.00/hr I . <br /> TOTAL DUE S Z T <br /> FOR OFFICE USE ONLY - <br /> SWEEPS = I COMPUTER LDC CODE DIS CODE AMOUNT RECEIVED CHECK �/CASH RECEIVED By GATE RECEIVED <br /> z S <br />