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SAN JGAWZX C =RT P'LLIC HEALTH SERVICES - EN12CI09WAL HEALTH OIVSICM <br /> IP0ERGtCL= STORAGE TANK PROC:R M - FEE (CRXSHEF' <br /> SFFA <br /> ITT SITE NAN J/,� FA{CJILIT7 Cw.. .T <br /> IO K I LO r 1 <br /> T <br /> EILE AOORESS .(� S E Px E With AREA CODE <br /> s S'U� Q!'�Cfvl ISG SU7q (204 42-lKZ <br /> A CITY rr_�s� E Z—F.�Z7i( atoSITE <br /> XS r <br /> P (7'LI/LCl t bl/t <br /> P APPLICANT/BILLING NAME APPLICY7 ACT NAA <br /> IAv,-1 <br /> C NAILING ACORESS APPLICANT PHONE 9 WITH AREA CODE <br /> T CITY .ATE Z P CWE TYPE of APPLICATION <br /> de c7i <br /> t) ,5'i (Closure, InstaLLaticn, etc.) <br /> TOTAL <br /> 1986 11987 1988 11989 1990 <br /> AI ANNUAL FACILITY FEE (Prior to laniary 1, 1991) = 5100.00 I I S <br /> C <br /> T FACILITY PERALTY FEES ASSESSED (If Applicable) I XXXX 17CCCX I I I 5 <br /> I <br /> V TANK rEE = 350.00/TANK (Prior as January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> Tanks = 1986 1987 11988 11989 11990 1991 11992 11993 1994 11995 11996 <br /> F (rul;i ply d cY fee for <br /> A eac- year ap_licable) I I I I I I I I S <br /> LTASK PENALTY FEES ASSESSED I XXXX I XXXX I I I I I S <br /> II S7A7E SURCAARGE = 556.00 each TANK (Due every 5 years) See Cali'ar..ia H 3 S Code, Section 25287 <br /> i <br /> YI o iarzs_ x S56.00 1986 through 1990 1991 chraugh 1996 <br /> amacnc and year) <br /> s <br /> i <br /> C; PERMANENT CLOSURE (Removal or AucSari:ed Closure-in-?lace) TANK I.O. 9(s) <br /> L� <br /> Cl C__SU,E F` - 573.00/hcur (3 hours minim. (TANK) I 3 TANX(s) 'X 52341.00 = S Lt, ua <br /> S <br /> UI iEciPCRARY CLOSURE (Plan Review 3 Inspectiors) I TANK I.D. :(s) <br /> El i-a°PCRARY C'_CSURE FEE = 573.00/hcur (3 hours minimm/TANK) I 3 TANK(s) X $234.00 = S <br /> P INSTALLATICN PLAN CHECK (PLan Review 3 Canstruetian Inspections)I TANK I.O. $(a) <br /> L <br /> A <br /> M PLAN CNE•CK EEE = 573.00/hcur (8 hours minimm/FACILITY) 5624.00 minirt S <br /> RI REPAIR FEE (Warkplan Review 8 Construction Inspections) I TANK I.D. S(s) <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minis m/TANK) IZ TANK(s) _ X 5234.00 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 573.00/hour (3 hours minimmlFAC I LITT) = 5234.00 minim S <br /> M TRANSFER FEE = $20.00 I I UHAUTHCRIZ2D RELEASE EVALUATION - 578.00/hr I S <br /> 9� I <br /> C CCHSULTATICH FEE = 573.00/hr I SAMPLING INSPECTION FEE = 573.00/hr I S <br /> TOTAL DUE 5 <br /> f OFFICE 115E ONLY <br /> SWEEPS X I CCMPUTER = I LOC CODE I GIST CODE I AMOUNT REC°IVEO I Lm; */CASHI RECEIVED 8T ( DATE RECEIVED 3 <br /> a I I S I I 3 <br /> EN 23 032 (REVISED it-1-92) Page 11 <br />