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SAN JCACUIN PUBLIC HEALTH SERVICES - ENVIRCNMEJITAL N IVSION <br />I CL= STORAGE TANK PROGRAM - FEE YCRXSHEETW <br />S <br />1 <br />FACILITY SITE NAME/ '' /I <br />�AA <br />1Pog LCUN� <br />1986 <br />FAACI1LIITY CONTACT NAME <br />�j�i..�.L bE"k) tvo'vv-' <br />T <br />1989 <br />1990 <br />(3 hours minimum/TANK) <br />E <br />FACILITY ADDRESS <br />?�LL7 <br />P <br />Sl;E ;)NoE # with AREA CODE <br />C'� 7 S li - 2�O <br />& <br />(Plan Review & Inspections) <br />( TANK I.O. <br />#(s) <br />A <br />CITY <br />2t Po N <br />$jATE ZCODE atit oSITENKS <br />/l/7/L <br />I # TANK(s)_ <br />X 2234.00 = <br />S <br />A <br />P <br />R <br />P <br />APPLICANT/BILLING NAME <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />S <br />APPLICANT <br />CONCT NAME <br />L <br />49AAe-6 <br />lull <br />-F 1lFf=lm <br />CFACILITY <br />f <br />=(x <br />XXXX <br />C <br />NAILING ADDRESS (� <br />I <br />V <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />AD LICANT PHONE # WITH AREACODE <br />N <br />T <br />CITY <br />SJATE <br />P CODE TYPE of APPLICATION <br />(Closure, Installation, etc.) 135POLM-L <br />TOTAL <br />C� <br />PERMANENT CLOSURE <br />1986 <br />1987 <br />1968 <br />1989 <br />1990 <br />(3 hours minimum/TANK) <br />I # TANK(s) <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />P <br />U <br />TEMPORARY CLOSURE <br />(Plan Review & Inspections) <br />( TANK I.O. <br />#(s) <br />El <br />TEMPORARY CLOSURE <br />FEE = S78.00/hour (3 hours minimum/TANK) <br />I # TANK(s)_ <br />X 2234.00 = <br />S <br />A <br />S <br />R <br />E <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />S <br />CFACILITY <br />PENALTY FEES ASSESSED (If Applicable) <br />=(x <br />XXXX <br />S <br />I <br />V <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br /># Tanks = <br />1986 1987 <br />11988 1989 1990 <br />1991 <br />1992 <br />1993 <br />1994 11995 1996 <br />FI <br />(multiply # by fee for <br />A <br />each year applicable) <br />I <br />I <br />S <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />I XXXX XXXX <br />( <br />S <br />L <br />[I <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T <br />YI# rank,- - x 556.00 <br />1986 through 1990 <br />1991 through 1996 <br />('Enter amount and year) <br />S <br />C� <br />PERMANENT CLOSURE <br />(Removal or Authorized Closure -in -Place) <br />I TANK I.D. <br />#(s) <br />SiCLOSURE <br />FEE = S78.00/hour <br />(3 hours minimum/TANK) <br />I # TANK(s) <br />Z 'X $234.00 = <br />P <br />U <br />TEMPORARY CLOSURE <br />(Plan Review & Inspections) <br />( TANK I.O. <br />#(s) <br />El <br />TEMPORARY CLOSURE <br />FEE = S78.00/hour (3 hours minimum/TANK) <br />I # TANK(s)_ <br />X 2234.00 = <br />S <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />S <br />II <br />L <br />A <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimm/TANK) <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) $624.00 minimum <br />S <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s)— <br />S <br />II <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimm/TANK) <br />Al TANK(s) X $234.00 = <br />S <br />C CONSULTATION FEE = S78.00/hr <br />SAMPLING INSPECTION FEE - S78.00/hr <br />A <br />S <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimm <br />S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />S <br />NI TRANSFER FEE = $20.00 <br />UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />S <br />II <br />S <br />C CONSULTATION FEE = S78.00/hr <br />SAMPLING INSPECTION FEE - S78.00/hr <br />S <br />TOTAL DUE I $ y�g � <br />.< OFFICE USE <br />i SWEEPS # COMPUTER # LOC CODE DIST CODE I AMOUNT RECEIVED CHECK #/GSH RECEIVED BY I DATE RECE IVEO ;3 <br />5 <br />EH 23 032 (REVISED 11-1-92) <br />