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SAN MAL, COUNTY PUBLIC HEALTH SERVICES - ERVIRONNE7I..�HEALTH DIVISION <br /> UMDERGROIRID STORAGE TANK PROGRAM - FEE wau=E <br /> ET <br /> S FACIL TY SITE NAME FACILITY COMMA NAME <br /> T jf4Cbflt/T <br /> E FACILITY ADDRESS C SITE PHONEAREA CODE <br /> L <br /> / '1' a3lt <br /> P <br /> CITY �� STATE LIP Dr $ of TANKS <br /> \J C � at SITE <br /> P APPLICANT/BILLING NAME I APPLICANT CONT' NAME <br /> L <br /> I �lL U <br /> C MAILING ADDRESS APPLICANT PHONE WITH AREA CODE <br /> M I WC -20 — D <br /> T CITY STATE ZIP CODE TYPE of APPLICATION r� .� <br /> (Closure, Installation, I..) <br /> TOTAL <br /> ( 1 1 <br /> ANNUAL FACILITY FEE (Prier to January 1, 1991) = 5100.00 1986 1987 1988 1989 1990 <br /> A XXXX 1 XXXX I XXXX XXXX XXXX S XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) 1 XXXX 1 xX%X XX)C( I XXXX XXXX 3 XXXXXXXXXXXXX <br /> t <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) s170/TANK (After January 1, 1991) <br /> rans E <br /> * kplY Y by fee far 1986 1 1987 1 1988 1 1989 11990 1991 1 1992 1993 1 1994 1 1995 1996 <br /> F mult <br /> A each year applicable) XXXX XXXX X%XX XXXX XXXX 1701 (loV701 1701170 /70 5 o. <br /> C 7 <br /> I TANK PENALTY FEES ASSESSED I XXXX I XXXX XXXX 1 XXXX I XXXX I /O 1 )1,1 1 7G 1 ( I D 7,1) S 1 <br /> L <br /> II STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H 3 S Cade, Section 25287 <br /> T <br /> T : Tanks/ x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amcunc and year) & I S& 1 <br /> S <br /> CI PERMANENT CLOSURE (Removal or Authorized CLasure-in-Place) I TANK 1.0. X(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minium/TANK) TANK(5)_ X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review i Inspections) I TANK I.D. '.(s) <br /> R <br /> E TEMPORARY CLOSURE F__ = 578.00/hour (3 hours minimum/FACILITY) 1 5234.00 minimus 5 <br /> P INSTALLATION PLAN CHECK (Plan Review 3 Construction Inspecrians)1 TANK I.O. 3(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workp(an Review 3 Construction Inspections) I TANK L0. x(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) 1 f TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.001hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = 5234.00 minimm S <br /> N TRANSFER PEE = SZO.00 1 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 1 S <br /> I 1 <br /> S <br /> G COMSUL7ATION FEE = 578.001hr I SAMPLING INSPECTION FEE = 578.00/hr 1 I S <br /> TOTAL DUE 15 <br /> J <br /> FOR OFFICE USE ONLY <br /> SWEEPS X 1 COMPUTER x LOC CODE I 01ST CODE AMOUNT RECEIVED CHECK */CASH I RECEIVED SY DATE RECEIVED <br />