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SAN JGAQUI41kffTY PUBLIC HEALTH SERVICES - EMVIRONMENTAWTH DIVSION <br />UNDERGROUND STORAGE TANK P - FEE WORXSHEET , ®d„ e72 <br />S <br />FACILITY SITE NAME C} eV124W SS -7 1 <br />FACILITY CONTACT NAME <br />I <br />T <br />1986 <br />1:7 WL4 E' �iba S <br />1988 <br />1989 <br />1990 <br />E <br />FACILITY ADDRESS <br />SITE PHONE 9 with AREA CODE <br />A <br />%%S77i f AGI �lG /4V�' <br />'iA <br />& <br />.. <br />=a XXXX <br />XXXX =a <br />=a <br />S XXXXXXXX <br />C <br />A <br />CITY 5, r® TL ^� <br />ATE <br />ZIP CODE <br />ffi of TANKS <br />at SITE '1, <br />P <br />T <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />I <br />lZtiL. `41W 604o f 64C . <br />CA,ALCI <br />XXXX <br />S XXXXXXXX <br />i <br />C <br />A <br />N <br />MAILING ADDRESS <br />113"1 N . MAC PbW LLA. wi•JD' <br />APPLICANT PHONE 9 WITH AREA CODE <br />-10-1 • -7 (O S t to 4 0 <br />T <br />CITY <br />STATE ZIP CODE I <br />TYPE of APPLICATION TEKja 06Svl't,lG, <br />fr <br />CA cl,"5*4- <br />(Closure, Installation, etc.)`N) ` irjw(,1 <br />TOTAL <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. 9(s) <br />L <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />S <br />A <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />A <br />U <br />=a XXXX <br />XXXX =a <br />=a <br />S XXXXXXXX <br />C <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/ FACILITY) <br />1 5234.00 minimae x IrS S <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX <br />r.= <br />=a <br />XXXX <br />S XXXXXXXX <br />i <br />V <br />TANK FEE = 550.00/TANK <br />(Prior to January 1,1991) I <br />5170/TANK <br />(After January 1, <br />1991) <br />E <br />0 Tanks = <br />1987 11988 1989 <br />1990 <br />1991 <br />1992 1993 <br />1994 <br />1 1995 <br />1996 <br />1 1997 <br />F <br />(multiply ;* by fee for <br />XXXX <br />XXXX XXXX <br />XXXX <br />XXXX <br />I <br />I <br />I <br />S <br />A <br />each year applicable) <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />=a XXXX =L( <br />XXXX fXXXX <br />I <br />S <br />L <br />I <br />STATE SURCHARGE _ <br />T <br />Y <br /># Tanks x 58.00 <br />1988 through 1990 (S56) <br />1991 through <br />1996 (S56) <br />1997 <br />SURCHARGE FOR 1997 <br />XXXX <br />S <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. 9(s) <br />L <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br />R TANK(s) X 5234.00 = <br />S <br />S <br />S <br />A <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. "(s) <br />R <br />S <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/ FACILITY) <br />1 5234.00 minimae x IrS S <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. f(s) <br />L <br />A., <br />N <br />PLAN CHECK FEE = S78.00/hour (8 hours minimam/FACILITY) _ 5624.00 minimum <br />S `T, (� <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections)I TANK I.D. "(s) <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br />I TANK(s) X 5234.00 = <br />S <br />A <br />I <br />R <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum <br />S <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum <br />N TRANSFER FEE = $20.00 <br />I <br />S------ <br />C CONSULTATION FEE = S78.00/hr <br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />SAMPLING INSPECTION FES = S78.00/hr <br />TO C -x i,'IP-01A <br />FOR OFFICE USE ONLY <br />SWEEPS COMPUTER 9 LOC CODE DIST CODE I AMOUNT RECEIVED CHECK <br />TOTAL DUE <br />1 1 <br />&-40— <br />fCA I RECEIVED 3Y <br />V A Q „= <br />2H 23 032 (REVISED 5-27-97) <br />3 <br />s <br />DATE RECEIVED <br />El <br />