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SAN JOACXJ;N TY PUBLIC HEALTH SERVICES - ENVIRD&I TAL HEALTH O(VSION <br /> ! STORAGE TANK PROGRAM - FET WORKS <br /> SI fAC3YTY SITE NAME I FAC{LITT CONS.. T NAME <br /> I ��ALV I..)i7 i4.L l.J�%' <br /> T <br /> E FACILITY ADDRESS c SITE NONE AO with AREA CODE <br /> & L 1 Z c J {-1 - <br /> CITY 1 STATE ZIP CODE S of TANKS 1 <br /> A I� IIt kyl r�lk �� 1 95 �Ii- at SITE <br /> P <br /> P APPLICANT/81LLING NAME APPLICANT CONTACT NAME <br /> L M __ <br /> C NAILING ADDRESS APPLICANT PHORE It WITH AREA CODE <br /> A <br /> N <br /> TI CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 7986 1987 1988 17989 17990 <br /> ANNUAL FACILITY FEE (Prior to Jw=ry 1, 1991) . $100.00 <br /> AI XXXX I %XXX I S <br /> C <br /> Tj FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX I X)= I S <br /> I <br /> V TANK FEE • 550.00/TANK (Prior t0 JalxWry t,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> I Yanks = 1986 1987 7988 11989 11990 i 7991 1992 11993 11994 1995 ( 19% <br /> F (multiOtY S by fee for <br /> A each year applieatde) X)= =cx I I I 5 <br /> G <br /> I TANK PENALTY FEES ASSESSEO XXXx XXXx I I I 5 <br /> L <br /> I STATE SUitC'IARCE = SS6.00 each TANK (Ove every 5 years) See California N & 5 Cade, Section 25287 <br /> i <br /> Y e Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> <Enter amOLnt and Year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Ctmsure-in-Ptace) I TANK I.O. s(s) <br /> I. <br /> 0 CLOSURE FEE = S78.00/hour, (3 hours mtnipum/TAHK) 9 TANK(S)_ X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & tnspectiorss) TANK t.0. S(s) <br /> R <br /> E TEMPORARY CLOSURE FEE • S78.00/hour (3 hours minimLWFACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TAN% 1.0. S(S) <br /> L <br /> l IA <br /> N PLAN CHECK FEE = S78.00/hour (8 hours mininLWFACILITY) = 3624.00 minis S <br /> RREPAIR FEE (workplan Review & Construction Inspections) TAN% i.0. i(S) <br /> E � <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimMITAN%) S :AN%(s) X 5234.00 5 <br /> A <br /> iTANK RETROFIT REPAIR FEE = 178.00/hour (3 hours min-/FACILITY) = S=4.00 miniaaAo S 3y1� <br /> R <br /> P(PiNC REPAIR FEE < S78.00/hour <3 hours minimuA/FACILITY) _ !M-00 minis <br /> NJ TRANSFER FEE = S20.00 I I UNAUTHORIZED RELEASE EVALUATION = S78.00/he I I S <br /> t I 1 <br /> S <br /> C CONSULTATtCN FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578_]0/hr S <br /> TOTAL Oi <br /> FOR OFFICE USE ONLY _ <br /> SWEEPS J COMPUTER 7 LOC 000E I 01ST CCOE 1 A?-CURT REC5IVED C:'.ECX d/CASH I RECEIVED 37� DATE RECCiVEOFs <br /> EH 23 032 (REVISED i0.28-93) 3 <br />