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LAM JOAQUIN COUNTYIII V PUBLIC HEALTH SERVICES <br /> 'i AM UNDERGROUND StAORAGE 01MATAL <br /> HEALTH DIVISI <br /> fACILI TT SITE NAME PROGRAM . FE KSHEET <br /> F <br /> A Ale <br /> pp FACILITY CONTACT NAI/i06&a <br /> FACILITY ADDRESS <br /> 23oA/�OGr7� �v�r <br /> T clTrSITE PHONE f with IVF® <br /> ,�y� <br /> Y /i�7&C $I TE 21P CCOE f of <br /> A APPLICANT/PILL(NO NAME c JOA imv <br /> P p APPLICANT CONT <br /> L JEtiYICd - ��Nf/kfkr I�s <br /> I MAILING ADORE" /0/4,77- <br /> C <br /> 0/L7 <br /> A 4�3 I W '7'G � APPLICANT PHONE if WITH AREA CODE - <br /> NCIT UD SJATE toy 6Z �(nS3 <br /> �SZO 2IP CWE TYPE of APplIGT10N p <br /> 9 ,rj'/ CLOSUIE, IMSTAIUTICN, etC. //Fir+p{/4It_ <br /> A <br /> C TOTAL <br /> 1 ANNUAL FACILITY FEE (Prior to Jeouery 1, 1991) a $100.00 1966 1987 1988 1989 1990 <br /> V <br /> E TANK FEE • $50.00/TANK ! <br /> (prior to Jarxwry 1,1991) $170 T <br /> F f TWca . / ANK (after January 1, 1991) <br /> A (multiply %byby fk for 1986 190T 1988 1909 1990 1991 1992 1993 1994 1995 1996 <br /> 1 C each year applicable) <br /> L STATE SURCHARGE • S56.00 each TANK (Due *veryg S <br /> years) Sea California N $ S Cod•, Section 25287 <br /> V!6.00 ._. . <br /> Y (titer recent 11 veer) 1966 through 1990 1991 thr <br /> aIn <br /> 1y1 1996 <br /> PERMANENT CLOSURE (Removal or AuthOrlEed Claure-In-PIEa) <br /> c <br /> L CLOSURE FEE • <br /> O $53.00 Per halt (3 hours einlsaa per TANK) <br /> NKU)_-__[_- N $159.00 <br /> S f TA <br /> RU TEMPORARY CLOSURE (A one-tier permit, for review/lnapectians) TANK I.D. IU) <br /> E TEMPORARY CLOSURE FEE • !150.00 each TANK <br /> f TANK($) N $150.00 . t <br /> L <br /> P PLAN CHECK (Install. Plan Review S Construction Inepeetton) TANS I.D. f(s) <br /> A <br /> N PUN CHECK FEE - $53.00 per hour (a hours minimum per facility) <br /> R REPAIR FEE (worN:pl an review $ 601`14truction Inspections) _ <br /> • P TANK REPAIR FEE • 553.00 TANK I.D. f(s) <br /> A per hour (3 hour* NlniayTANK) IF TANK(e) <br /> I IT $159.00 • ! <br /> R PIPING REPAIR FEE • S57.00 per hour f3 hau �Inl�us par faclltt • <br /> Y $159.00) s <br /> N TRANSFER FEE a $20.00 l$IAUTNOIIIED RELEASE EY <br /> ALWlick . $53.00/hr <br /> Y $ <br /> C CONSULTATION FEE • S53.00/hr lANPL IND INSPECTION FEE <br /> l53.00/hr $ <br /> OFFICE USE Y <br /> _ TOTAL DUE <br /> Sale lit <br /> r r�+n•.warA"it•wirwA i�.•"irii+w":w:r.w::wwwi..»: -__`'!pp <br /> MreealrArM w••�•M.+riwin.. ^' - ._ L/ / <br /> ENrrrrewr•awrwrr.w,tRrww`u•»;::;�:::»,�:- ;2:'�« ._.___ - •. v-`j ,;.... <br /> 23 032 (REV 4/8/911 it rrr.r.w.la.,ar.wnrAw uau.••rr.o•�ir•:,:.:;w;.:: <br /> PAN 11 <br />