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SNI JOAOUIN C -Y PUBLIC HEALTH SERVICES - ENVTRONK91TAL 1 ' .TH DIVSION <br />MA, -(GROUND STORAGE TANK PROGRAM - FEE YORKSHEL., <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />T� <br />- \- <br />P C-<- <br />E <br />FACILITY ADDRESSI <br />1 <br />SITE PHONE r- With AREA CODE <br />I <br />ANNUAL FACILITYFEE(Prior to January 1, 1991) = $1 00-00 <br />CITY <br />STATEN <br />ZIP CODE m Of TANKS <br />AI <br />L <br />I C <br />I at SITE <br />P� <br />CI <br />PI <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />�I <br />A' u Q oN,7=5 <br />FACILITY PENALTY FEES ASSESSED (If Appticamte) <br />-- I v Z <br />C, <br />MAILING ADDRESS V., <br />U <br />VI <br />APP CANT PHONE : WITH AREA CODE <br />"! <br />N <br />ZlS` Lv X U\(D <br />I <br />3 - 4 <br />T <br />CITY <br />STATE <br />ZIP CODETYPE of APPLICATION <br />1995 11996 <br />rj <br />(Closure, Inscattaci on, tcJ <br />C' PERMANENT CLOSURE (Reaovat Or Authorized Closure -in -Place) I TANK !.D. :(S) <br />01 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) I s TANKCS)_ X 5236.00 = 1 S <br />S' <br />Ui TEMPORART CLOSURE (PLan Review d Insoeetions) I TANK I.O. :(s) <br />R <br />Ej TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimah/FAMITY) I ST36.00 minimus ( S <br />PM INSTALLATION PLAN CHECK (Plan Review & Construction InS0eCti Oes)I TANK I.D. '-(S) <br />L / <br />Al <br />NI "LAN CHECK FEE = 578.00/hour (8 hours minimAun/FACILltt62 <br />> = 56.00 mi niovo S_ / <br />RI REPAIR FEE (Workatan Review d Construction Inspections) I TANK I.D. :(S) <br />PI TANK LINING REPAIR FEE= S78.00/hour (3 hours minimum/TANK) I X TANK(s) X 5236.00 = 5 <br />A <br />II TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) a 5236,00 minimum S <br />R <br />PIPING REPAIR fK 578.00/hour (3 hours minimm/FACILI7I') = $234.00 minimum S <br />MI TRANSFER FEE = $20.00 I I UNAUTHORIZED RELEASEE :VALUATION = S78.00/hr I I S <br />� i I <br />S <br />Cj CONSULTATION FEE = 578,00/hr � I SAMPLING INSPECTION F_E = 578.00/hr I S <br />T AL DUE <br />6�qG — GYw� GQ(k S -()J _ <br />-OR OFFICE USE CULT ,c G _'cz "y <br />DATE R_LIVEO <br />SWEEPS = COMPUTER = LOC CODE DIST CODE AMOUNT IEtVED CHECK -/GSH I RECEIVED 3Y <br />u <br />TOTAL <br />1986 11987 1988 <br />1989 1990 <br />1 <br />I <br />ANNUAL FACILITYFEE(Prior to January 1, 1991) = $1 00-00 <br />S <br />AI )D=xxxx xxxx <br />CI <br />Tj <br />FACILITY PENALTY FEES ASSESSED (If Appticamte) <br />I xxxx I xxxx I xxxx <br />I <br />I S <br />U <br />VI <br />TANK FEE • SS0.00/TANK (Prior t0 January 1,1991) <br />I 5170/TANK (After January <br />1, 1991) <br />I <br />9 Tan"pct-, 1986 11987 11988 1989 j <br />1990 1 1991 11992 1993 199E <br />1995 11996 <br />1 <br />FI <br />OY fey {oI <br />Al <br />each Year 4o0lioe0lel xxxx I %XXX I lOIXX I i <br />I I I I ( <br />I I <br />S <br />C. <br />II <br />TANK PENALTY FEES ASSESSED I xxxx xxxx I XXXx I <br />I I I I I <br />I ( <br />S <br />L' <br />!I <br />STATE SURCHARGE IS0 each TANK (Due every 5 years) <br />See California N S S Code, Section <br />25287 <br />T1I. <br />Tanks_2 x 55Y(t10 �3.L I 1988 through 1990 <br />1991 througn 1996 <br />1 <br />CEnter amount and year) <br />C' PERMANENT CLOSURE (Reaovat Or Authorized Closure -in -Place) I TANK !.D. :(S) <br />01 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) I s TANKCS)_ X 5236.00 = 1 S <br />S' <br />Ui TEMPORART CLOSURE (PLan Review d Insoeetions) I TANK I.O. :(s) <br />R <br />Ej TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimah/FAMITY) I ST36.00 minimus ( S <br />PM INSTALLATION PLAN CHECK (Plan Review & Construction InS0eCti Oes)I TANK I.D. '-(S) <br />L / <br />Al <br />NI "LAN CHECK FEE = 578.00/hour (8 hours minimAun/FACILltt62 <br />> = 56.00 mi niovo S_ / <br />RI REPAIR FEE (Workatan Review d Construction Inspections) I TANK I.D. :(S) <br />PI TANK LINING REPAIR FEE= S78.00/hour (3 hours minimum/TANK) I X TANK(s) X 5236.00 = 5 <br />A <br />II TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) a 5236,00 minimum S <br />R <br />PIPING REPAIR fK 578.00/hour (3 hours minimm/FACILI7I') = $234.00 minimum S <br />MI TRANSFER FEE = $20.00 I I UNAUTHORIZED RELEASEE :VALUATION = S78.00/hr I I S <br />� i I <br />S <br />Cj CONSULTATION FEE = 578,00/hr � I SAMPLING INSPECTION F_E = 578.00/hr I S <br />T AL DUE <br />6�qG — GYw� GQ(k S -()J _ <br />-OR OFFICE USE CULT ,c G _'cz "y <br />DATE R_LIVEO <br />SWEEPS = COMPUTER = LOC CODE DIST CODE AMOUNT IEtVED CHECK -/GSH I RECEIVED 3Y <br />u <br />