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• i <br /> SAN JMCt1IN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UmDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FS <br /> FACILITY SITE NAME FACILITY C T T NAME <br /> I � fi� E N with AREA CUOE <br /> E fACILIiY ADDRESS /\ <br /> SI© <br /> T <br /> STATE ZIP CODf,— of TANKS r2 <br /> CIiT at SITE <br /> l i oao fuo <br /> P ` 4 <br /> P APPLICANI/BILLING NAME / f APPLICANT CONTACT NAME <br /> L — lC C ,� C Qr C_o <br /> APPLICANT �PH/O'NE N WITH AREA CODE <br /> AZINGC ADDRESS Y"6q---E�IZZ3 <br /> N <br /> T CITY STATE IIP CODE TYPE of APPLICATION <br /> ®L � r (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) ■ $140.04 <br /> xxxx xxxx $ <br /> A <br /> Gxxxx xxxx s ' <br /> I FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I <br /> V TANK FEE _ %50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1941) <br /> E <br /> N Tanks = 1986 1967 1988 1989 1440 1991 1942 1993 1944 1995 1996 <br /> F (multiply N by fee for = <br /> A each year applicable) xxxx xxxx <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx % <br /> L <br /> I STATE SURCHARGE . $56.00 each TANK (Due every 5 years) Sae California H L S Code, Section 25287 <br /> T — <br /> T N Tanks x 556.40 1988 through 1990 1991 through 1996 <br /> (Enter amofnt and year) _ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-In-Place) TANK I.D. N(a) <br /> L0 TANK(s) X $234.00 $ <br /> 0 CLOSURE FEE ■ %78.00/hour (3 hours minimnnV'TANK) <br /> R <br /> S <br /> U TEMPORARY CLOSURE (Plan Review S Inspections) TANK I.D. #(a) <br /> R <br /> E TEMPORARY CLOSURE FEE - $78.00/hour (3 hours minimua/TANK) N TANK(s) x $234.00 i <br /> P INSTALLATION PLAN CHECK (Pian Review L Construction Inspections) TANK I.D. N(s) <br /> L <br /> A <br /> N PLAN CHECK FEE _ %78.00/hour 01 hours minimum/FACILITY) =624.00 minimum t <br /> R REPAIR FEE (Workplan Review b Construction Inspections) TANK I.D. N(s) <br /> E <br /> P TANK LINING REPAIR FEE r (78.00/hour (3 hours minimlm/TANK) N TANK(s) X $234.00 $ <br /> A ■ $234.00 minimum $ <br /> 1 TANK RETROFIT REPAIR FEE - 578.00/hfx�lr (3 hours min./FACILITY) <br /> R ■ $234.00 minimum $ <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimun/FhCIL1TY) <br /> N TRANSFER FEE - %20.00 UNAUTHORIZED RELEASE EVALUATION ; S78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE ■ $78.00/hr SAMPLING INSPECTION FEE * %78.00/hr S <br /> TOTAL DUE 9 <br /> FOR OFFICE USE ONLY !I IIIIlIII Ft[!!'lIIIIHI TIEi!Ffil!{dI{llllil 11111 111 lllmll'Illmmmmlimp Iltllfll mill IE!ESiIIAlR1111111!111lf 11FAI1!mm1pIIIfIIp1111mi1Hml! II{IHIFEE!11{!q immd1333 li!{I11m I it mNl!!F <br /> fllEll i!!I Ilii ilillallllll II i i!1 II I Ilii I�p1 III II 'II III II!il.11 II I p f �p �p �� pp !! �I�Imm p� ry p <br /> II!il11iIIIIIIIIIIIIII!IIIIIIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIill!IUIIIIIIIIIIILLIII[IlifllllfllllllFlkllf3mIll]II11111111111111111111111111111111111mItl14U11111111111111111i1i1i!{{1111IIIIIIIIRIillllllgllllnllllllplllll1111111H11lIpWIIIIII111N1ElEFId3{111111{IHlfiiil{{yfIm1111111mImFI�NI pUII111tlIlIINN1 1 <br /> SWEEPS N COMPUTER N LOC CODE DIST CODE AMOUNT RECEIVED CHECK N/CASH RECEIVED BY DATE RECEIVED <br /> 'll <br /> II $ <br /> �I'rilllillillllillllilillllllliilillili Ilillllilllliliiiilllililiiiliuiliiii IIiiIIIIIiIIIIiIIIlIl1i111iliill 111{ii1111l11iIu1111ullllliilllilll IlllillllllllllllllllilllllllllJIIIIIIIIIIIIIllIS1Il IllllllllllliullkilCl{I31IlIifllllllllllllll Illlllllllllllilllll=I111aIllIIIIII�IIIIWII�lllull Il��illll111si1II�i {III>�Iq��IIIUIII�! <br /> EN 23 032 (REVISED 6-21-93) Page 11 <br />