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SAN JOAOUI11 C Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> OUND STORAGE TANK PROGRAM - FEE WORKSH <br /> 5 FACILITY SITE NAME FA LITY TACT NAVE / <br /> T F T J otil # �o 7Q ,CL)Ku j0 <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> g 2I n 3 rnA-Ru-/ LAA, <br /> CITYC ` ST TE ZIP CODE # of TANKS <br /> A Srt��.tOIU g$20 at SITE ou <br /> P <br /> P APPLICANT/BILLING NAME APPVCANT CONTACT NAME <br /> C MAI 1E ADORESS APPLICANT PHONE # WITH AREA CODE <br /> N Z o Sr ' ep 44 SZ <br /> T CITY I ST TE ZIP CODE TYPE of APPLICATION <br /> 952a7— (Closure, Insta(tation, etc.) GAS a <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = E100.00 1986 1987 1988 1 1989 1 1990 <br /> A f <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) KKKK KKKK E <br /> 1 <br /> V TANK FEE E50.00/TANK (Prior to January 1,1991) $170/TANK (After1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 M A 1996 <br /> F (multiply # by fee for <br /> A each year applicable) <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX KKKK 1 <br /> L Zan v;jpj <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S C Ion 252 <br /> T <br /> Y # Tanks z 556.00 1986 through 1990 1991 throw ` k/yF <br /> (Enter amount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 178.00/hour (3 hours mini mum/TANK) # TANK(s)�_ K $234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimun/FACILITY) = $234.00 minimum - S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) - <br /> L <br /> A <br /> N PLAN CHECK FEE = 178.00/hour (8 hours minimm/FACILITY) = 1624.00 <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I. ��• .y�" <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) K :5234.00. f <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = 1234.00 m( ,\ Y� f <br /> R <br /> PIPING REPAIR FEE = 178.00/hour (3 hours minimm/FACILITY) = 5234.00 m f <br /> M TRANSFER FEE = 120.00 UNAUTHORIZED RELEASE EVALUATION = 178.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = 178.00/hr <br /> I it) TOTAL DUE 2 3 <br /> FOR OFFICE USE ONLY <br /> .................................. ............................................................................................................. ....................._..................................... ............_............... <br /> xe.=.m.=a:eeee.zr zeee.iw seer xe�xee»xw zee»zw zee»zw zw zeee�zn Yeew w. aw..r..aaw xw a..r.r arww�r�rrwwww» <br /> L�I�O SL Ac� °x <br /> a <br /> A ga <br /> g.............. . ..„;� LL., 3 r <br /> . _ .� . : .r .» .,. .». .rr.r.rr :» .r». .rr.».r . .. w: : .... :; .... ;, ,.., <br /> "+ 73 132 !REVISED 3-1-93) • Paae 11 • <br />