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SAN JCACt1IN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION i <br /> UNDE.' ,JHO STORAGE TANK PROGRAM FEE WCRXSHEET <br /> FACILITY SITE VANE FACILITY CONTACT NAME <br /> F <br /> A <br /> C 7 -1 S /�:(G( �l c C'X -'Y C-C' S J '1 <br /> I FACILITY ADDRESS SITE PHONE t with AREA CODE <br /> f v . "lcz 7 v q - L( 3Y$ 7 <br /> T CITY STATE LIP CODE 5 of TANXS <br /> Y 1 UGl" �!/Y7 Cid CJS )_J/ I at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P (`/e-//1 r%le" C 'V/c /—inC /cam <br /> I ,WILLING ADDRESS 70 APPLICANT PHONE it WITH AREA CODE <br /> V CITY // STAiE ZIP CODE APPLICAT ICN <br /> T 1C t w'f �,G�.LSr'J(7 LOSUR�I NSTALLATICN, etc. <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> I 5 <br /> '/ <br /> E TANK n-= = S50.00/TAHK (prior to January 1,1991) &170/TANK (after January 1, 1991) <br /> F 2 Tanks = 1986 1987 1988 1989 1990 1 1991 1992 1 1993 1991. 1 1995 1996 <br /> A (aultiply SY fee for <br /> C each year applicable) S <br /> I <br /> L STATE SURCHARGE = S56.00 each iAXX (Due every 5 years) See California H 3 S Code, Section 25237 <br /> 1 <br /> T [-7T;rks— z 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter a and year) <br /> S <br /> PVU,.MEHT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. :(s) , <br /> C <br /> L CLOSURE FEE - 553.00 per hour (3 hours minimum per TANK) S TANK(s)� 7159.00 S is <br /> 0 <br /> S <br /> U TEMPCRARY CLOSURE (A ore-time permit, for review/inspectlors) TANK t.D. S(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - $150.00 each TANK X TANX(s) X 5150.00 = 5 <br /> P PLAN CHECK (UsstaLL. Plan Review 5 Corstnaction lnspect toms) TANK I.D. f(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = S424.00 minimum s <br /> R REPAIR FEE (workplan review & construction inspectiors) TANK I.D. Y(s) <br /> "c <br /> P TANK REPAIR FEE - S53.00 per hour (3 hours ,ainInmVTAXX) Y TANK(s) X $159.00 S <br /> A <br /> I <br /> R PIPING REPAIR FEE = S53.00 per hour (3 hour minimum per facility = 5159.00) S <br /> N CCNSUITATICNS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = S53.00/hr FEE = 5 53.DO/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> _- P 3-7� �'ANU�yO/ � 3d3s <br /> ssa�rsswassw�tssssirs»ssssarrassa�ar'a�s�s��sssssAi�ssas=isa=os <br /> EH 23 032 (REV 1/10/911 ft ... Pace 11 ..r <br />