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SAN JOAWIM IC HEALTH SERVICES - E)NVi R01NWWTAL IVSION STORAGETANK PROGRAM - FEE WORXSRE <br /> FACILITY CONTACT NAME <br /> S FACILITY SITE NAMES S -)4 �Ak c� L <br /> 1 l 0 / S/'tom aC l(v . <br /> T SITE PHONE # with AREA COD <br /> E FACILITY ADDRESS <br /> & STATE ZIP CODE # of TANKS <br /> CITY G ? at SITE <br /> A <br /> P �uw t. , (��, APPLICANT CONTACT NAME �� Cly <br /> P APPLICANT/BILLING NAME ��'j.y v4' S-� c,�G 1_ 44 <br /> ! H : S-�-e <br /> L sx'.vcr� •' T Tt <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS ��9 <br /> A r� �- S /V U✓[.L cE-i� <br /> N STATE ZIP CODE T .pL:blf,ApPLICATION <br /> T CITY S CLosure,� nstallation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 $ <br /> A <br /> C xxxx xxxx $ <br /> T FACILITY PENALTY FEES ASSESSED (If Applicab Le) <br /> 1 $170/TANK (After January 1, 1991) <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) <br /> E 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> # Tanks = <br /> F (multiply #__'oy fee for $ <br /> A each year applicable) <br /> C $ <br /> I TANK PENALTY FEES ASSESSED xxxx %XX% <br /> L <br /> 1 STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See La ifornia H & S Code, Section 2528 <br /> T1986 through 1990 1991 through 1996 <br /> Y # Tanks z $56.00 <br /> (Enter amount and year) $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) <br /> TANK I.D. #(s) <br /> L # TANK(s) $234.00 = $ � <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minim.m/TANK) <br /> S TANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R $ <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimm/TANK) # TANK(s)_ X $234.00 = <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A = $624.00 mini mm $ <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimm/FACT LITY) <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E $ <br /> PFTANK <br /> INING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = <br /> A S <br /> IETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) 5234.00 minimmR = $234.00minimum $ <br /> REPAIR FEE _ $78.00/hour (3 hours minimun/FACILITY) <br /> N TRANSFER fEE <br /> $20.00 UNAUTHORIZED RELEASE EVALUATION E- S7B.00/hr f <br /> IS $ <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE 578.00/hr <br /> TOTAL DUE $ Clr <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED 8Y D _ <br /> EH 23 032 (REVISED 11-1-92) • Page 11 , <br />