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e SAN JMUIJIN CUAiTY PUBLIC HEALTH SERVICES - EHVIROKKENTAL HEALTH DIVSION <br /> ' UNISER TORAGE TANK P90GRM - FEE UORKSHEET Adkk <br /> FACILITY SITE NAME <br /> FA[I L t TY CONTACT NAHt <br /> T <br /> 111 V 15 1 i � GGY �RCZS 04(-L <br /> E FACILITY ADDRESS <br /> SITE PHONE # with AREA CCOE <br /> q o , � s� l,ov,s� AYE , a09 - s as - � a <br /> CITY /� STATE ZIP CODE # of TANKS <br /> P �s-T���Q� �0 �1 � � � at SITE <br /> a <br /> P APPLICANT/BILLING NAME <br /> L Y) � �� APPLICANT CONTACT NAME <br /> I R�GHAiZ� <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A tia +� 5T <br /> T CITY Dq_ Sad- � <br /> S STATE ZIP CODE TYPE of APPLICATION <br /> � 33(y (Closure, Instaltation, otc,} �=VP- <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1986 1987 1988 1989 1990 <br /> A <br /> C 5 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX <br /> I ; <br /> '1 TANK FEE = S50.00/TANK (Prior to January 1,1991) <br /> E 5170/TANK (After January i, 1991) <br /> # Tanks = 1986 1987 1988 1989 1494 <br /> F (multiply by fee for <br /> 1491 1992 1993 1994 1995 1996 <br /> # <br /> A each year applicab(e) <br /> C S <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX <br /> L 5 <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & 5 Code, Section 25287 <br /> T <br /> Y T Tanks x $56.00 1986 through 1490 <br /> (Enter amount and year) 1991 through 1996 <br /> _ S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> D CLOSURE FEE = S7$.00/hour (3 hours minimum/TANK) # TANK(s) o{ X $234.40 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review $ Inspections) <br /> R TANK I.D. #(s) <br /> F TEMPORARY CLOSURE FEE = 578.00/hour (3 hours mini <br /> mus/TANK) # TANK(s) X $234.00 = 5 <br /> L P INSTALLATION PLAN CHECK (Plan Review S Construction Inspections)l TANK I.O. #(s) <br />,5 <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) <br /> = s624,00 minimus 5 <br /> REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> TANK LINING REPAIR FEE = S78,00/hour 0 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> I TANK RETROFIT REPAIR FEE = 478.00/hour 0 hours min./FACILITY) $234.00 minimum <br /> S <br /> PIPINt REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br /> S <br /> M� TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78,00/hr <br /> S <br />.I <br />' CONSULTATION FEE = 578,00/hr SAMPLING INSPECTION FEE = 578.00/hr <br /> TOTAL OU f ,(16 <br />'R OFFICE USE ONLY <br /> .- <br /> — __ =z—.-nom_. - _ <br /> SWEEPS # COMPUTER # LOC CODE"UriGIST CODE ^AMCUH7 RRECEIVEDMVCHECK �/ 5 � RECEIVED BY OA E RECEIVED <br /> iii <br /> 23 032 (REVISED 11-1-92) Page 11 <br />