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SAN JOAEXJIX O+JMTT PUBLIC HEALTH SERVICES - E)Ivin*(EXIAL HEALTH OIVSICW <br /> 1- ERGRCUMO STORAGE TANX PROGRAM - FEE UOR'SNEF' <br /> SI FAC TY SITE NAMEI FAC LITT CON, CT NAME <br /> 1 /)ivW11 L w 1 ' J) u,LA <br /> Tr SITE HORE X w(th AREA CODE <br /> E FACILITY ADOR_SS <br /> _ 47-0 C0 QLVrila011 ' 9,2'1 2.0 00 <br /> CITY STATE ZIP CODE e of TANKS <br /> �IA CJK � at SITE <br /> A I�IAA�CF4 ✓ _ <br /> P <br /> P APPLICANT/81LLING MANE APPLICANT CONTACT MAKE <br /> IM <br /> C MAILING ADORES$ APPLICANT PHONEY 9 WITH AREA CODE <br /> A <br /> M STATE ZIP CODE TYPE of APPLICATION <br /> TI CITY <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 11986 1987 � 1988 I 1989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 <br /> A ( KKKX 130= I 5 <br /> C <br /> Tj FACILITY PENALTY FEES ASSESSED (If Applicable) I X)= I roo, I I S <br /> I <br /> V TANK FEE 550.00/TANK (Prior YO jatwary 1,19911 SS70/fANX (After January 1, 1991) <br /> E <br /> d Tanks < 1986 1987 1986 11989 11990 11991 1992 11993 1994 1995 11996 <br /> F (muLiiptY =_W fes for <br /> A each year aWiCeble) 1000( =cx 5 <br /> C <br /> I TANK PENALTY FEES ASSESSED 7>C<YY'I X1000 I I I I 5 <br /> L <br /> ISTATE SURCHARGE = $56.00 each TANK (Due every S Years) See California N & S Code, Section 25287 <br /> T <br /> Y S Tank,_ x $56.011988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Plece) I TAIL[ I.D_ s(s) <br /> L <br /> 0 CLOSURE FEE - 578.00/hour (3 hours mfnfawa/TAHX) S TANX(s)_ X 5234.00 = s <br /> S <br /> U TEMPORARY CLOSURE (Plan Raviaw i Inspecticrs) TAHt I.D. S(s) <br /> R <br /> E TENPOkOf CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimun S <br /> PIMSTALLAYION PLAN CHECK (Plan RaViaw i Construction Irsspecti ono) TAMX 1.0. s(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = $78.00/hour (8 hours miniu./FACILITY) = 3624.00 miniamaa S <br /> RI REP0.1R FEE (Varkplan Raview t Construction Inspections) TANK f.0- l(s) <br /> E � <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimtm/TAMIq I : :ANX(S) X 5234,00 = S 3St <br /> AT <br /> I TANK RETROFIT REPAIR FEE � S78.00/hour (3 hours min-/FACILITY) = S234-00 miniamaa S �3.. <br /> x <br /> PIPING REPAIR FEE < 27$,00/hour (3 hours minimal ACILITY) = X4,00 miniamaR S 3- <br /> MI TRANSFER FEE 520.00 I I UNAUTHORIZED RELEASE EVALUATION - S-,MDOfhe I I S <br /> if <br /> S <br /> C COHSULTATIOM FEE = 178,00/hr I I SAMPLING INSPECTION FEE 578-X/hr I S <br /> TOTAL DUE S C�l — <br /> FOR OFFICE 115E ONLY <br /> won aiw s s�sa� <br /> SUEEPS M I CCKPUTER Y LOC +BOE DIST CO)C 1 %-CAT 7ECEIVEO C{ECz d/CASH I RECEIVED 3Y DATE RECCIVED 3 <br /> I � S <br /> FN Z3 03Z (REVISED !0.28-93) 3 <br /> IiiT-+1 F 117 <br />