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SAN 4GAQUINPUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> WGR= STORAGE TANK PROGRAM - FEE HORKSH <br /> FACILITY CONTACT NAME <br /> SIFACIL TY SITE NAME �� _ • , <br /> 1 d cf' T PivL�u l iIVICL <br /> T ��. I SITE PHONE 9 with AREA CODE <br /> "E FACtLf T�Y1 ADDRESS r -- fes- /�✓` <br /> CITY STATE ZIP CLUE �'. or TANKS <br /> A :Sr // at SITE <br /> TD C- { 52°✓L/ <br /> P APPLICANT CONTACT NAME <br /> PI APPLICANT/BILL NAME <br /> L <br /> I APPLICANT PHONE.N WITH AREA CODE <br /> C MAILING ADDRESS <br /> 3au0 41e c°vTc Cog 5L77 - 3�� <br /> N <br /> I S- 7.1p CODE TYP<- of APPLICATION •3 U-5 <br /> T CIiY�, �G [L �+� . I (Clasure, (nstallation, etc-) IP <br /> �T / TOTAL <br /> 1986 11987 11988 1989 11990 <br /> ANNUAL FACILITY FEE (Prior Co January 1, 1991) = 5100.00 XXXX I XXXX I an XXX% I XXXX 15 XXX%XXX% <br /> C� <br /> A <br /> T FACILITY PENALTY FEES ASS'cS5E7. (If App(icable) XXXX XXXX XXXX XXX% )O%XX S xxxxxxxx <br /> I51701TANK (After lanuarY 1, 1991) <br /> V TANK FEE = 550.00/TANK (Prior Ca larwary 1,19917 <br /> E <br /> ; : Tanks = 3 X.��C 11988 11989 1990 ( 1991 11992 11993 1996 11995 11996 5997 11998 <br /> FI (multiply by gee far I I I I 151 D 151 015i 6 �Sl D Si 015%0 !16G�__ <br /> Al each year applicable) XXXX XX%X XXXX XXXX XXX% �y ?? <br /> Cl I� iANK PENALTY FEES A5S_.ssa I XXXX XXXX I XXXX I XXXX IxxxX IJi D I6i o I5101,5i 6 I x516151 O I s36 <br /> L: S F/' 50 <br /> II STATE SURCHARGE FOR HEW FACILITIES ONLY-SI-8.50 <br /> T 1988 Through 1993 (556) I 1993 thraugh 1997 (556)1 5998 <br /> YI : Tanks x 58.00 I <br /> SURCHARGE FCR 1998 I XX%%XXXX7-xmxxXXXmxx%xxx I XX%%XXX==xxxxxxxxxx I 15 ,1 r+ 60 <br /> C{ PERMANENT CLOSURE (Re aL or Authorized CSasure-in-Place) I TANK I.D. :(5) <br /> Li : TAWS)_ X 5236.00 ' I S <br /> OI CLOSURE FEE = S78.00/hour (3 hours miniaam/TANK) <br /> Si TANK [.0. :(s) <br /> UI TEMPORARY CLOSURE (Plan Review 3 InsPec-ions) <br /> Ai I S <br /> Ei TEMPORARY CLOSURE F"cE = 578.00/hour (3 hours minimWFACILITY) I 5734.00 minimuD <br /> PI INSTALLATION PLAN CHECK (P[an Review 3 Canstructian ImPectiare)I TANK t.0. T(S) <br /> L 1 <br /> A 1) S <br /> NI PLAN CHECK FEc = 578.00/hour (8 hours minimm/FACILIT7 = 5624.00 minirmm <br /> RI .REPAIR FEE Workplan Review 3 CGnstrUctian SnsPectio ) I TANK I.O. 3(s) <br /> EX 5234.00 = S <br /> P TANK LINING REPAIR FEE = 578-00/hour (3 hours mi nimam/TANK) N TANK(s) <br /> As <br /> s <br /> E <br /> I TANK RETROFIT REPAIR F = 578.00/hour (3 hours min./FACILITY) 5234-00 ,mini" <br /> RI <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimlCD Q34 <br /> /FACILITY) - .00 minim. Su <br /> Mj TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE VALUATION = 578.00/hr I <br /> ;;T;;; <br /> I <br /> CI CONSULTATION FEE = 57B-00/hr I SAMPLING INSPECTION FEE = 578.00/hr I I S <br /> TOTAL DUE s D� / T J <br /> FOR OFFICE USE ONLY <br /> SWEEPS x.. CCMPUTER A LCC CODE DIST CODE AMOUNT RECEIVED CHECK .'./CASH I RECEIVED 3Y I DATE RECEIVED - <br /> I 1 5 <br /> EH 23 032 (REVISED 1-12-98) • <br />