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SAN JOACUi TY PUBLIC HEALTH <br /> RGRgpm STORAGE iW PROGRAM TAMFEENTH DIYSION <br /> S fAC! I Y SITE NAM <br /> I �� 0 <br /> T C <br /> E FACI�IT �CILITY <br /> A00 E S CT NAME <br /> S TE PH HE # ui AREA CODE <br /> DI TY ' s9r'-Z7Z3 <br /> A ��PbAct <br /> P SE ZIP CODE <br /> P APPL CANT/BILLING NAME SS ? a of TANKS <br /> at SITE <br /> I try O� �(�p� AkPIlCAXT CON Ci NAME <br /> C MAILING ADORF1 �1 <br /> A <br /> N 2 — 4Av/ <br /> PLICA PHONE # 4i AREA2 ODE <br /> T ccrw,�`�� PHONE <br /> KK.•.• �E Z ��E 7YPE of APPLl CA7ION <br /> Installation, <br /> etc.) <br /> I ANNUAL FACILITY FEE (Prior to January TOTAL <br /> A ry 1, 1991) = 5100.00 1986 1987 1988 <br /> C 1989 1990 <br /> 7 FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I 5 <br /> V TANK FEE = SSG-OO/TANK XXXX XX%X <br /> FEE <br /> £ (Prior to January 1,1991) t <br /> # Tanks = 1986 1987 5170/TANK (After January 1, 1991) <br /> F <br /> (multiply #by fee for 1988 1989 1990 1991 <br /> A each year applicable) 1992 1993 1994 <br /> C 1995 1996 <br /> I TANK PENALTY FEES ASSESSED <br /> L I %XXX XXXX <br /> S <br /> I STATE SURCHARGE = $56.00 each TANK (Due 5 <br /> TIT every 5 Years) See California H I S Code, Section 25287 <br /> # Tanks_ x 556.00 1986 through 1990 <br /> (Enter amount and year) <br /> � 1991 through 1996 <br /> S <br /> C PERMANENT CLOSURE (Removat or Authorized Closure-in-place) <br /> L TANK I.D. #(s) CP <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimus/TANK) 3 11 � <br /> S # TANK(s)�_ 'X $234.00 = <br /> U TEMPORARY CLOSURE (Plan Review I Inspections) 5 Z <br /> R TANK I.D. #(s) 1 C� 17A) V <br /> E' TEMPORARY CLOSURE FEE = S78.00/ho # TANK(s) <br /> (3 hours mini mAn/TANK) fd s) <br /> NK(s)�_ X $734.00 = <br /> S <br /> P INSTALLATION PLAN CHECK <br /> L (Ptah Review I Construction Inspections) TANK I.D. #(s) <br /> A <br /> Al PLAN CHECK FEE = S78.00/hour (8 hours minimWFACILITY) <br /> = $624.00 minimus <br /> s <br /> R REPAIR FEE (workplan Review I Construction Inspections) <br /> E TANK I.D. #(s) <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimuNTANK) <br /> A # TANK(s) <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) , X $234.00 = S <br /> R $234.00 minimum <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) 5 <br /> = 5234.00 minimus <br /> t <br /> M TRANSFER FEE = $20.00 <br /> I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br /> 5 E <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br /> t78.00/hr <br /> t <br /> .1 OFFICE USE ONLY TOTAL DUE S 'ZZ <br /> . — _-- <br /> SWEEPS # - — -- <br /> COMPUTER # <br /> LOC CODE GIST CODE — --- <br /> AMCUNT RECEIVED CHECK Al/CASH/CASH RECEIVED BT <br /> DATE RECEIVED <br /> H 23 032 (REVISED 11-1-92) Page 11 <br />