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SAN JCA N COUNTY PUBLIC HEALTH SERVICES - ENVIRONNENI L HEALTH DIVISION <br /> ERGROUMD STORAGE TANK PROGRAM - FE'e <br /> SI FACILITY ITE NAME qw FACILITY WACT NAME <br /> ' <br /> I� <br /> T1 I <br /> E FACILITY ADDRESS SITE PHONE �'. 'With AREA CODE <br /> I f1 <br /> CITY STATE ZIP CODE Sof TANKS <br /> A as SITE <br /> Post-it®Fax Note 7671 Dale pages 3 - Post-it•Fax Note 7671 Da _'LO'O!"� paoges; _3 <br /> (\ _/ From ../ A A —� <br /> TO ]� From "(,� TO USQ H `JCI ,I C�1tG-Y <br /> Co./Dept Q Cos-Q-_ PbL3 fUtr2 A. CoJDePt Co. <br /> Phone# /v Phone# 6 j _ Phone# Phone L✓ 341 <br /> Fax 3 _73Z4 Fax1. 6 .3 Fax A�3- -73 2-4 Fax# q_ 6� <br /> ANNUAL FACILITY FEE (Prior so January 1, 1991) - 510000. 1 <br /> A Xxxx l xxxx Xxxx l Xxxx I Xxxx S xxxxxxxxx=X <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) 1 Xxxx Xxxx 1 Xxxx 1 Xxxx xxxx 5 XXXXXXXXXXXXX <br /> ` INly�- � <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> EF;(t <br /> Tanks = 1986 1987 1988 1989 1990 1992 1993 1994 1995 1 1996 57Fmultiply 3 by fee forAeach year app(icable) Xxxx Xxxx X%XX 1 Xxxx 1 %XXX 1 70 x'70 1 /70 1r7(7T/770� y0� /0 Z.0 <br /> II TANK PENALTY FEES ASScSSED Xxxx Xxxx 1 )GOO' xxxx Xxxx 01 0 1 0 1170 AD 0 <br /> L' <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H a S Code, Section 25287 <br /> Y : Tanks x15tr.G0 S98@�'hrac9h"1990 -f94L °'rgi2'aGL' 17 <br /> (Enter amount and year) <br /> C1 PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK 1.0. 4.(S) 7 <br /> L <br /> 0 CLOSURE -EE = 578.00/hour (3 hours ninimm/TANK) x TANK(s)_ X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review a Inspec:ions) iANK I.O. 2(S) <br /> 21 S <br /> EI TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) ' S234.00 mini" <br /> P INSTALLATION PLAN CHECK (Plan Review 3 Construction Inspecticns)I TANK (.0. *(a) <br /> L <br /> A S <br /> N PLAN CHECK FEE - S78.00/hour (8 hours minimum/FACILITY] = S624.00 minimum <br /> R REPAIR FEE (Workplan Review a Construction Inspections) TANK 1.0. x(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 haat^ mi nimm/TANK) 1 X TANK(s) % 5234.00 = S <br /> A minimumS <br /> I TANK .2ETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 minim <br /> R s <br /> PIPING REPAIR FEE = 578.00/hour (3 hours mininxm/FACILt TY) = 5234.00 minimum NI TRANSFER FEE = $20.00 UNAUTHORIZED RELEASEE EVALUATION = S78.00/hr 1 S <br /> Si <br /> Cl CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = S78.00r S <br /> /h <br /> TOTAL DUE S2,0 <br /> FOR OFFICE USE ONLY — _ <br /> SWEEPS S COMPUTER d 1 LOC CODE DIST CODE AMOUNT RECEIVED I CHECK S/CASH I RECEIVED RY OAT C RECEIVED <br /> S <br />