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SAN JCACUIH CCUNTY PUBLIC 4EAL14 SERVICES <br /> ENVIRCNMENTAL ',HEALTH 01VISICN <br /> UNDER• 40 STORAGE TANK PRCGRAM - ._= WORKSHEET <br /> FACILITY SITE NAME FAC;L[TY CONTACT NAME <br /> A / <br /> C <br /> FACILITY ADDRESS SITE ?,4E with AR= Ei L� <br /> Z)� <br /> CITY _ G SiA 2IP C�E� of TANKS <br /> a <br /> at SITE vJ <br /> A APDLICANT/3ILL[NC NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I NAILING ADDRESS ` / APPLICANT PHONE ;* WITH AREA CODE <br /> A <br /> H CITY �J AT ZIP CODE TYPE of APPLICATION <br /> CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> 1986 11987 1988 1989 1990 <br /> i ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> I � <br /> /rte in6l/c"7S /C6 i 00 S s'no <br /> TANK FEE = S50.00/TANK (prior to January 1,1991) S170/TANK (after January 1, 1991) <br /> F 4 Tanks � 1986 1987 1 1988 1989 11990 1991 1992 1993 ( 1994 11955 1996 <br /> A (aultiply t-Sy t'ee for <br /> C each year applicable) /GO J llC�l DG /DIA /Ul> �!O 3w1 S �( <br /> STATE SL'RC:URG`c = 556.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25297 <br /> 1 <br /> T '. Tarks x 556.00 1986 through 1990 1971 through 1996 <br /> Y (enter amount and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. :(s) <br /> C <br /> L CLOSURE FEE = S53.00 per hour (3 hours minim per TANK) I TANK(s)_ X $159.00 = S <br /> 01 <br /> S <br /> U TE4PCRARY CLOSURE (A ore-time permit, for review/inspections) TANK I.D. #(s) <br /> iE4PCRARY CLOSURE FEE = 5150.00 each TANK x TANK(s) X 5150.00 5 <br /> P PUN CHECK (Instal L Plan Review S Corstructicn Inspections) 1 TANK I.D. i(s) <br /> L <br /> A <br /> N PUN CHECK FEE - S53.00 per hour (8 hours minilmm per Facility) = S424.00 mini mm S <br /> R REPAIR FEE (workplan review 3 ccrstmction inspections) TANK I.D. '(s) <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimun/TANK) Y TANK(s) X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE = S53.00 per hour (3 hour minim per facility = 5159.00) S <br /> N CCNSULTATICAS UNAUTHORIZED RELEASEE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C1 FEE = S53.00/hr 1 FEE = S53.00/hr FEE = S 53.00/hr 1 <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> ..._4._-w...-...LO-C�-""�'1-'_.._...o_....-..--.._....-_--i nE` ._^/...'.......-_..................__--...._L._-_ <br /> `al�'sfia-ml?:umgp ao qr'°�Y fie{——zwa�a�a pga.'rq�y's ,�yy—issn ....-y..—sa'(a.—ea <br /> AI <br /> ]wcEfS 1,G4�lllC{ � e 1JI C � N1l.LN1 IC�U ��il (1 {G l_l'ICJ 3i C [Cl_t�CJ Y <br /> II I <br /> ER Z3 732 (REV 1/10/911 ft Pace 11J- <br /> 7 <br />