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!! <br /> SAN JOArA11M [aUNty PUBLIC HEALIN SERVICES <br /> �.. ENVIRONMENTAL HEALIN DIVISION Iwo <br /> UNDERGROOR <br /> )ND STORAGE TANK PROAN - FEE UORKSHElt <br /> + 1ACllitl 611E NAME FACILITY CONTACT NAME <br /> A Mildred be Vincenzi BobBesselt_ine_ _ <br /> — _ <br /> I IACIl1tY AOORfff III It ?NONE / Nl th AREA CODE <br /> 1 2116 N. TTethewa Rd <br /> T 9I 931�34B6 _ <br /> 1 city !TATE 21P CODE 1 of tANKS <br /> T Acampo, Ca 1 at 211E 1 <br /> 95220 <br /> A APPUCANI/sIttINO NAME APPLICANT CONTACT NAME <br /> P <br /> Mildred be V111cenzi same <br /> L <br /> ` "AILING ADDRESS 1226 E Eight Mile Rd- APPLICANT PNOE 6 UI IN AREA CODE <br /> A <br /> (209) 931-3486 <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> 1 clo1URE, INSTALLAt1ON, ate. Removal <br /> A IOtAL <br /> C 1966 1927 1982 1969 1990 <br /> I ANNUAL UCIUtT FEE (Prior to Jerwery I, 1991) • 1100.00 <br /> R ! <br /> F TANK FEE • 550.00/TANK (prier to January 1,1991) 11170/LANK (after tertiary 1, 1991) <br /> t 0 Tenke • 1966 1967 1986 1969 1990 199) 1992 1991 1994 1995 1996 <br /> C tech year applicable) ! <br /> 1 _ <br /> L STATE SURCHARGE • 156.00 each TANK (Due every S yearn) See Celifornle N S S Code, Section 25267 <br /> 1 <br /> 1 f IN,*e N 156.00 1986 through 1990 1991 through 1996 <br /> Y (enter ;Fwr t and year) <br /> f <br /> PERMANENT C109URE (Removal or Authorlted Cloeure-In-Pleee) TANK I.D. 6(a) 464 <br /> C <br /> L CLOSURE IEE a 651.00 per hour 0 hours minlmua per TANK) / TANK(§) R 6159.00 1 159.00 <br /> 0 <br /> s <br /> U TEMPORARY CLOSINIE (A one-time permit, for tevleN/Inepeetlons) LANK I.b. 6(A) <br /> R <br /> E TFNPOUIRY C1051ME PEP • 1150.00 each TANK 6 tANK(a) IT !150.00 1 <br /> P PUN CHECK (Install. Plan Review S Corntructlon Impaction§) LANK I.b. 6q) <br /> l <br /> A <br /> N PIAN CHECK IEE - $51.00 per hour (A hour§ minlmm per Fact l Ity) a !424.00 minimae f <br /> R REPAIR IEE (workplan revleu E construction Inspectlons) LANK I.D. 60) <br /> E <br /> P TANK WAIN FEE • 1151.00 per flour 0 heura minlnu,t/tANK) / TANK(§) — R 6159.00 • t <br /> A <br /> I <br /> R PIPING REPAIR FEE • 151.00 per hour 0 hour minlars per facility a 11159.00) t <br /> 141 CnRSULIAIIOINS UTAUtNORIZEO RELEASE EVALUATION SAMPLING INSPECTION <br /> C FEE • 251.00/hr FEE a 151.00/hr FEE • 11 WOO/hr <br /> TOTAL DUE 1 Ir <br /> OFFICE USE ONLY <br /> ......... <br /> ..... we..r_Mfr_�..,.,.,_+�.........w.aJrel_.y ..wa........ �wlrfFlelM/l� (y,�_ y <br /> rSth FT'S Rw �'UIFN 11 lt)l CUA 015'1 L'(!l[ w /11tx1H1 eC9U.- M LX[�R II�i�511 �NFLErvc��w� V111 x�W <br /> rl•W W 1•i•W •i <br /> is+n--y iTGr7r WYrI••,MrF•,••r•••M•,••r i••w:•www•r:w"i••iw i..,' •••••• """i •w•w+w"ir r.:iw.+ww`•rit.w rw S::.. <br /> w•••r rWwwNrwrlNl wllwvwww W MrwWMWWWew M'MWW nwYWWTW tWtAN MIN wMY wM MA%ww WV wWWe w WN W MI wYlwwYw <br /> FN 23 012 (RFV 1/10/91) It Oeae I <br />