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SAN ,IQAOl1INTY PUBLIC HEALTH SERVICES - EMVIRCUPOdTT H DIVSION <br /> ORGWJW STORAGE TANX PROGRAM r FEE <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T <br /> _;�Ua ?�7 7 �cr� A�P7' sr2of/- <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & //3I Sarre �'�o�Cr©� Sr�E� eo9 f�f d90 <br /> CITY STATE ZIP CODE # of SITE A s�aC�rt> 9S2o6at <br /> P <br /> PAPPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A 9.3/ eJxgr"-,71,1mr5' f�o�l� 209 S2 9653 <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION / F/IJf�(/fJy <br /> AloA4F97O 9jr � (Ctosure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S10D.00 <br /> A S <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) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX LXXXX S <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 x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> CI PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) ,� X $234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minima/TANK) # TANK(s) X $234.00 = S <br /> P INSTALLATION PLAN CHECK (Pian Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimua/FACILITY) = $624.00 minimum 5 <br /> R REPAIR FEE (WorkpLan Review & Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = ^578.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = M.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE a 578.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED - <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />