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i <br />HEALTH SERVICES - ESR AL IEAI.T Ys2oN <br />r SAN JOAoItI X COUNALIC <br />U=rRGRcupa t'louca TANK PROGRA9 FEE NOBfO;7OT <br />FACILITY c6aACT NAME <br />S <br />fA6Tt,iTT SITE NAME <br />I <br />T <br />LU�'TYL-LSI-�(A'�- LTJ L • v <br />SITE PHONE; # with AREA CODE <br />E <br />FACILITY ADDRESS <br />3 5 ti. � /�-� <tio� - �� 3 5 <br />i <br />STATffIi�of TANKS <br />it <br />CITY � <br />SITEPRLICANT!CONTACT <br />NAME <br />p <br />:APPLICANT/8ILLING NAME <br />Rd-1'M E-alt-P-� <br />I, <br />APPLICANT 9 WITH AREA CODE <br />C <br />MAILING ADDRESS L , -? <br />�� 3 <br />Or �Pf4 •A�l E <br />STATE ZIP COOS TYPE of APP <br />T <br />CITY Z (C14sure, EnstaLtation etc.) <br />'�-•� <br />TOTAL <br />1986 1,987 1988 1989 1990 <br />FACILITY FEE (Prior to January 1, t991) _ $100.00 <br />S <br />ANNUAL XXXX XXXX <br />A <br />C )0=�QOOC <br />FACILITY PENALTY f>:ES:AMSSSO (If Applicable) <br />_ <br />T <br />I5170/TANK (after JOnuarY 1, 1991) <br />TANK FEE 550.00/TANK (Prior to January 1,1991) <br />V <br />E 1986 1987 1 1988 1989 1990 1991 199 11993 1994 1995 1996 <br />0 Tanks = <br />F (pAtiptY by fee for <br />S <br />A each year applicable)• XXXX X)0« <br />C <br />I TANK PENALTY FEES ASSESSED XXXX XXXx <br />S <br />L <br />I CHARGE = $56,00 each TANK (Out every 5 years) See Catifornis N & S Code, Section 25287 <br />T 1988 through 1990 1991 through 1996 <br />Y x $56.00 <br />�(Enter <br />ount and year) <br />S <br />ANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.0`. #(S) <br />URE FEE = S78-00/hour (3 hours miniasm/TANK) 9 TANI((s),,..e_ X 5234.00 = <br />$ <br />PORARY CLOSURE (Alan Review & inspections) TANK I.D. #(s) <br />FT'E <br />PORARY CLOSURE FEE = $78.00/hour (3 hcurs minimum/FACILITY) $234.00 minigum <br />CHECK (Plan Review b Construction Inspections) <br />ON PLAN <br />EINITALLA" <br />ECK FEES _ S78;,-00/hour (8 hours miniaun/FACILITY) = 8¢24.00 minimum <br />`�� <br />Review & Construction Inspections) TANK I.D. 40s) <br />R REPAIR FEE (Workplan <br />E, 0 TANKS) X $?34.00 <br />FE=u-s7=8.G0/=hour(3 <br />rh=ours=minipuWTAXK) <br />P TANK LINING REPAIR <br />A$ <br />FEE = 378.00/hour (3 hours rain,/FACILITY) = $234.00 mininxua <br />I <br />TANK 2ETROFIT REPAIR <br />R <br />� PIPING REPAIR FEE,'578.00/hour (3 hours minicaoyfACILITY) = S234.00 minimum <br />$ <br />= 520.00 UNAUtItOREZEO RELEASE EVALUATION <br />TRANSFER FEE <br />LISC <br />a.S78.0O/hr CONSULTATION FEE = S78.00/hr SAMPLiHG INSPECTION FEE <br />TOTAL DUE <br />_ "CID <br />FOR OFFICE USE ONLT nuia—�—=- <br />_. <br />—_ <br />g r _•--[p�n�m r •.•., • <br />.,;:niunlII:r.�m----_—N311uti9it>t^a=T:----- i <br />AMOUNT RECEIVED CHECK CASH RECEIVED SY 1 <br />= LOC CODE I DIST CCOE #/ <br />GATE RE I D <br />a SWEEPS Y COMPUTER I I <br />:yq• ._.,:::::_-sone+ _-� ammnmalnnlu — -� <br />�--^r=—_.__. ..4:IIUu�—_�il7nll.:w___.....y!iq�•=_—ice <br />—:.... <br />al .° <br />tl'�.:::—�:ytilltlullLk:E:!..=---�nJ111P:� ,• <br />EH 23 032 (REVISED IO-28-93) <br />_ <br />TrT".1 G + • <br />