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I, SAN JOAGUIN <br /> CONTY REL <br /> EMVIR01RtM1AL HEALT <br /> N DIVISION <br /> ERGRCUND STORAGE YANK PROGRAM - IEE wDRKS <br /> 1 <br /> �FACILITY SITE NAME FACILITY CONTACT NAME <br /> A <br /> C <br /> I FACILITY ADDRESS 1/ I � j ftTE PHONE / with AREA CODE <br /> IC <br /> T CITY !?AYE 2IP CODE / of TANKS �- I •(✓`1JLr+ ��`� <br /> f <"',l.. C., - �� �t�i Ot-E at SITt .nTE <br /> A APPLICAMT/BILLING NAME APPLICANT CONTACT NAME <br /> P I _ <br /> L '''SR•�r��:=,n-tit^ �:�G lCc rcr _ <br /> 1 <br /> Cl IMG ADDRESS APPLICANT PHONE 5 WITH AREA CODE <br /> A <br /> 41f I <br /> M CITY + !TAE 2IP <br /> Y r DI E�fTYPE of APPLICATION <br /> CIJSRE, INSTALLATION <br /> , ♦te. .�:�J., I,�.l_ <br /> -'- TOTAL - <br /> p <br /> r - 1986 1987 <br /> 19e8 1989 1900 <br /> I ANNUAL FACILITY FEE (Prior to January 1, 1991) e !100.80 <br /> S <br /> I <br /> V <br /> E TANK IEE 150.00/YANK (prior to January 1,1991) !110/TANK (after January 1, is 1) <br /> F a Tanks . 1986 1987 1988 1989 1990 1991 1992 1993 1996 1995 1996 <br /> A (multiply a by fee for <br /> c tech year applicable) <br /> I <br /> L STATE SURCHARGE • $56.00 each TANK (Due every S years) See California N It S Cede, Section 25287 <br /> T a lank% A $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter Maim and yrar) <br /> E <br /> PFRMANFNT CLOSURE (Removal or Authorized Closure-ln-Place) TANK I.D. #(a) <br /> C <br /> L CLOSURE FEE • $53.00 per hour (3 hours mini" per TANK) S TANK(S)-J— X 5199.00 • f � <br /> O L <br /> U TEMPORARY CLOSURE (A one-time permit, for review/InSpaCtlaN) TANK F.O. SIR) <br /> R ___ <br /> F TEMPORARY CLOSURE FEF. • $150.00 each TANK S TANK(!) y,— N 5190.00 • E <br /> P PLAN CHECK (Iretsl(. Plan Review S Corsstructlon IrspeCtlont) TANK I.D. R(a) <br /> t __ <br /> Af <br /> N PLAN CHECK FEE $53.00 per hour (8 hours mini aASII par Peelllty) • 1624.00 minimus <br /> R REPAIR FEE (Varkplmn review S construction Inspections) TANK I.D. SU) <br /> F J K !159.00 f <br /> p rANK REPAIR rE9 • $53.00 per hour (3 hours minlaum/TANK) 5 tANK(a) <br /> R PIPING QEPXIR FEE %53.00 per hour (3 hour minimurn per flelllty E1111159.001 <br /> j N <br /> six TAT IONS y UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> S <br /> /ht FEE • E53-00/hr FEE • ! 53.00/hr _ <br /> TOTAL DUE <br /> ' OrFiCL USE ONLY <br /> .......... <br /> r-:w,'».Gv+w.•«.:Y::iiSiw..»»,w.«wusaw:a»a«wd+w+w•aiiilit:OA'i:♦fiT:ikKitiK(AY Ni,YNNisa7Yii7iJAAY.Yiiii'wi i'SK.YAT:Y � � �te <br /> B""ELr'E?'•i"�"" 7�i+Yh'E�"il m'["u�'ctb. "'Itl"s'i"`c'tb'�"' •tl5tiflAlY•�'t'tllf"" �CA�C'A/t.A�1C•' '1rL'E'f�f�"iC <br /> S STr •e:wwNa ..0 ..Jou.: -: . ./.1........y.,..... <br /> a <br /> . v <br /> a.................... ....._. ........... ALSt AW <br /> 46 <br /> iaitAfaR;.'T,'SiV s;«:. <br /> you a,wi�::rwwT. •. •our waxes+:r�w«a..B iiiAWi eeetWmeNWAw WWtla%W Wefie na cure Yt ave asi <br /> t:a tlY l~in.i Yr sa%,u tlFr 11W malgtY M'M tgtY HY'M!\1U 1ktlCYe Ylltlaa W ar W <br /> FN 21 032 (REV 1/10/911 it PMS 11 <br /> I <br /> I <br />