Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
SAN JOII )IM COUNTY PUBLIC WEALTH SERVICES ENVIRONNMAL WEALTH OI IOM <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> IAP440 L�'1 M #ir Z\-, 0.14TSP1J w 1¢i In(). <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & <br /> CITY STATE ZIP CODE # of TANKS <br /> P 6,JjpI�iK.-jG�J, (16, CAc"jZICO at SITE s� <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT WANE <br /> u�4T�©N u�Or7T, t rc �l L,c_ ws�T+ J <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A *&.dm ,d1 Wor-N 0KIuD• ,IUe 3 -3OLPLO <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> G,�1GjR.A.1'lpf.7TZ� (je- G,c�$4 (Closure, Installation, etc.) <br /> n <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX $ <br /> I <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply 4# fee for <br /> A each year applicable) db $ &S"O'0 <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX f <br /> L <br /> I STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks 4y x $56.00 1986 through 1990 1991 through 1996 C, <br /> (Enter amount and year) / <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(a) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TAWK(s) X $234.00 = i 93 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(a) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A ], <br /> N PLAN CHECK FEE ■ $78.00/hour (8 hours mihimun!/FACILITY) ■ $624.00 minimum <br /> R REPAIR FEE (Workpian Review & Construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE - S78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ <br /> N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION - $78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> ?i??iw:?:??i9lYulflti!f.Y:=• '' .acf::»!:»f?9&7 <br /> Nu'!i?uq??iM <br /> tt SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK !!)ASH RECEIVED BY DATE CEIVED <br /> :-U;3 Al 9 4111, of -a� s y o0 3 �� _3/y <br /> � � <br /> ?3?i?!!??i?ii:t%???t!i?::itL=N!a?.:?Nr::8343•.!Ni3:.!°:iZIS?? m'=i.}i°R3i ?:f !� ?!L'�? 'SIC•Lp!?9:''i!'5iL'�rw!?:�8?L ir•.'.e°L°F!c?L•IS?.iFi???9u�i!?!!!!?ai{i's7H3.-: L4N!k:.9}iL°.'.�.9!!ii23fi9P.0lS!:i&ii:eii:i: <br /> M. ME?6'=.= ••• x !L? •]#ituli?tfSli?f!Ni0!?9G6£67ll ... ,'•••r-=3??i:?i8 <br /> EH 23 032 (REVISED 11-1-92) Page 09 <br />