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SAN JaAoUtN CCUNtY PUOLIC HEALTH SERVICES <br /> ENVIRONMENtAL HEALTH DIV14)ON <br /> UNDERGROUND STORAGE TANK POOGAAM Y FEE tOKSHEET <br /> FACILITY SITE HARE FACILITY CONTACT NAME <br /> FF <br /> i <br /> A z —��'�n-r Ac: � a �` U j ►� yC n is ti <br /> C SItt PHONE 0 with AREA CODE <br /> I FACILITY ADDRESS <br /> L ,�tt. .� <br /> 1 STATE tip CODE 0 of TANKS <br /> T CITY ti I At SITE <br /> Y :STCx- v'1 � '� �� <br /> APPLICANT CONTACT NAME <br /> A APPLICANT/BILLING NAME <br /> P <br /> ,1_11 \ !St q z cam, t- �-c �- K <br /> L <br /> APPLICANT pHONE ! g1tH-ARE A CCOE <br /> I LING ADDRESS 4�L4 —g 3*3 <br /> C �' ,ES6 � <br /> N C�LY STATE tip [ODE TYPE bf AINSTALLATI <br /> LICATION <br /> CLaSURE� INSTALLAttON, etc. <br /> tOTAL <br /> A i98b 1997 ilea 1489 Talo <br /> C <br /> T ANNUAL FACILITY FEE (prier to January 1, 1491) 1100.00 t <br /> 1 <br /> IV <br /> E TANK FEE • 150.00/TANK (prior to Janurry 1,1990 1170/TANK (Ott+r Jefx,ary 1, 1941} <br /> F 0 Tanks r 1986 1987 1988 1989 1990 1491 1992 1493 1994 1995 1946 <br /> A (multiply R by fee far ! <br /> C each year opptleebte) <br /> T <br /> L STATE "CHARGE 'A 156.00 etch TANK (Due !very Yeert) See Catifamli N t S Codly soctlbn 25287 <br /> t <br /> T a ranks x 156.00 1986 through 1990 illi through 1996 <br /> r (enter 'j o t and year) S <br /> PERMANENT CLOSURE (Removat oh Authortied Ctosur*•In-Plsee) TANK 1.0. 0M <br /> C !! <br /> L CLOSURE FEE + 15].00 per hour (3 hours mtnt" pbr tANK) S tANK(!) It S1S9.00 <br /> 0 <br /> 5 <br /> U TEMPORARY CLOSURE (A Ot*-tim► permit, for rev1#0 t Inspection! TANI( t.o. #M <br /> C TEMPORARY CLOSURE FEE a 3158.00 Itch tANK t!'tANK(s) 'X 11S0.00 s ! <br /> P PLAN CHECK (Install. Pion RtvI6W S ConithUctlen Inspections) tANt( t.01 NO) <br /> L <br /> A <br /> H PLAN CHECK FEE - 153.00 Per hour to hours mint" per theItlty) a lxZ4.h0 nrinlmtiH <br /> EpAtR � I Pin r' � It - I'e L wt 1.6, S(ti) 2 -61 <br /> P TANK REPAIR FEE * 153.00 per hour Q3 hours ih1nlmum/tANK) 0 tANKM I !159.00 : ! <br /> A <br /> R PIPING REPAIR REVIEV ! CONSTRUCTION A =53.00 per hour 0 hour m�nitittel POP fittltty A MOM) <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUAt10N SAMPLING 190E010N <br /> S <br /> C FEE - 153.00/hr FEE + 153.00/hr FEE e ! 53.0d/hr <br /> TOTAL DUE ! <br /> OFFICE USE 0NLT <br /> .._ •.,^:,:.:r::. :.:.:.�N:.y,.:.n xiiN iai�i viir xw w,�wai.,o..uiu:a,wws�eaw.v`,oa».ai�earieer+ia.+se.:;�e:state ao�v,i:+e«�.w,ir�i.»»»,w,w�:.w.:�:.M:...ww.ir ti..s.:.uw n:.:��:. <br /> y' rlr ` Film <br /> S! `eL � c 17�asx. C1ECCCAI j's'E ` ' `Ae E�"�'rSi ( ` <br /> ...w:w lw lw lwi.}IM wwwfNfrr:w 5i ie.!Wi Yep YKM rei»rIMIJ,eF 7l,eaPYNAg70FfnM 70^"A,.wF!fC9M 9t[1 sr�f"w ww+ ON <br /> ww�lw r,:�rwlw,r f,n w�.„i.T�IIFM.w sr <br /> rr far Ns.ww�M�+tI�rM MR HM!lt ::'3 iCCY,',Y'tS.'L"NY:"..5.^.'".l:Y'9RE'Al",`.'�"M`X:J!'�7'5 KK�'S'.°ft'X':'ClR'.# `�` A101 s1RlMM ImIMrl let tNtf flM�r�Y'IM Ms/�wll� <br />