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SAN JOAO(jIN OwNNTY PUBLIC WEALTH SERVICES - ENVIRMPIENTAL HEALTH DIVSIOM <br /> UNDERQNOLM0 STORACM TANK PROGRAM - FEE ►xx IREET <br /> EKAILIXQ <br /> SITE NAME FACILITY CONTACT NAME. <br /> I�cJ�vr l�f C(e_� �����/ �vG� � � <br /> 11719 r,r s r N e>~ A0 a A "I <br /> A004233 o _ C- I -) -jd ' Y <br /> STATE 2IP CODE o of 1ANX2 <br /> at SITE <br /> APPLICANT CONTACT NAME <br /> T/rILLIN4 NAIL o } L <br /> Ir <br /> �, ,� �C r ✓ c� /G< ��Ys / LAPPLICANT PHONE r 41TM AREJI rnoE <br /> ADORESl�� � -� fiit4'0L'f <br /> STAT! ZIP CODE APPLICATION <br /> Y �r s G t J -'�.j r, Inatallatlon, tu.3 <br /> TOTAL <br /> 1966 1467 1968 1469 199Q <br /> ANNa1AL FACILITY FEE (Prior to January 1, 1991) !100.00 ! <br /> A <br /> CX)0(JI )Dt)0( ! <br /> T FACILITT PENALTY FEES ASSESSED (if Appllcabls) <br /> I3170/TANK (Attar JarrnrY 1, 1991) <br /> V TANK FEE • 150.00/TANK (Prior to Jaraury 1,1991) <br /> III Tanks . 1966 Igor 19sa 1969 1990 1991 1992 149! 1994 IM 1996 <br /> F ctultlp(y Tly fea for ! <br /> A tach year bMtIcoble) <br /> C t <br /> I TANK PENALTY FEES ASSESSED xxxx NC7Qf)f <br /> L <br /> I STATE SURCrARGE 156.00 tach TANK (out every S year!) t*e Caiifornia N i S Coda, Soction 25267 <br /> T1966 through 1990 1991 through 1996 <br /> T 1 t■nko Ne 156.00 <br /> (Enter �t " year) ! <br /> C PERMANENT CWSMI (Remove( or Authorized C(oz7n-Place) TANK I.D. rta) <br /> L r rANKc•) X 1234.00 s <br /> 0 CLOSURE FEE • 17E.00/hour (3 hours iainiszWTANK) <br /> S TANS T.D. r{s) <br /> U TEMPORARY CLOS( l (Plan Review i Irxrpaetlons) <br /> R ! <br /> E TEMPORARY CtMRI FEE • 17'5.00/haul` (3 hood ■Inl=WFACILITY) a MA-00 �lnleaRl <br /> MEN <br /> P INSTALLATION PLAN CHECK (Pion Ra"M i Conatruotion InopoCtlana) TANK I.D. Eta) <br /> L <br /> A • 1624.W rinl 1 <br /> N PLAN CHECK FEE + 1T8.00/hour (5 hours alniw V FACILITY) <br /> R REPAIR Fit (Yorkplsn Ravlow R Construction trrpoctlorr) LANK 1.0. r(s) ti, 15'Ix <br /> E ,u'� " <br /> P TANK LINING REPAIR FEE • 178.00/hour (3 haus a11MIMOM/TANK) � t TANK(s) �—�—X �.� • 1 Com' �~ <br /> A • $234.00 ■inisam <br /> I TANK RETROFIT REPAIR Fit • t7E.00/hour (3 hours min./FACILITY) <br /> R ■ ! <br /> PIPING REPAIR FEE • 975.00/1Tour (3 haxe rinlaaaa/FACILIdY) - <br /> N TRANSFER Fit • !20.00 IAiAUTNORIZED RELEASE EVALUATION 6 <br /> 1 <br /> C CONSULTATION FEE • !71.00/hr WNPLIN4 INSPECTION FEE 11A.00/hr <br /> TOTAL DUE 1 <br /> FOR OFFICE USE ONLY x <br /> r.w r-Tr�'�Tr Ri.*Ti.��rr w w'�Y■i rrrr ."Ti .`x+r "mwmwiw INS ■ <br /> �rrr+"�'iw moew�...iw,tai■wrw.rrFrAe.see.wtrae■r�+a�■ararwrF�■trs#r�aawwF�twa� rr.w rrrsrrrrsrtai .rr.�rusr■srRtR+aew <br /> EN 23 M (REVISED 3-1-431 • Pont 11 0 <br />