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6yh�x <br /> SAN JCAQUINMUTY HEALTH SERVICES - ENVIRONMENTAL "6TH DIVISION <br /> UljPMZCUNO STORAGE TANK PROGRAM - FEE WORKSH <br /> S FACILITY SITE NAME �] FACILITY CONTACT NAME <br /> I Ge G Tk <br /> T �) c-�e&2 �- <br /> E FACILITY ADDRESSi SITE PHONE S u h AREA CODE <br /> CITYSTATE ZIP CODE 4 of TANKS <br /> P 'i C �Yi.' Y(..) C _ZR� at SITE / <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I <br /> -, J 6 � <br /> C MAILING ADDRESS l APPLICANT PHONE t WITH AREA CODE " 7' <br /> N 1� <br /> T CITY V�O STA E ZIP CLUE I iYP APPLICATION <br /> C� S lasur nsta k ation, etc.) <br /> TOTAL <br /> 1986 1987 1988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXx xxxx XXXx XXXX xxxx S XxxxxXxXxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (I£ Applicable) I xxxx I xxxx I xxxx xxxx xxxx S xxxxxxxXxxxxx <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> F At Tankply S by tee tar 1986 I 1987 I 1968 I 1989 1990 1991 1992 1993 1994 1995 1996 Trr,(* <br /> A each year applicable) xxxx xxxx xxxx xxxx xxxx i70I %70I (7C� j7o lTO I J70 5 / ' <br /> C <br /> I TANK PENALTY FEES ASSESSED I X)!XX xxxx I xxxx I xxxx I xxxx 1701 i7DI t SDI 7LI i 7�) 70 S / ) L? <br /> L <br /> II STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25287 <br /> T <br /> Y : Tanks / x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> ZnJo1Le�' b33 t �� sv � V C,1nJlA�c�o333�0 <br /> C' PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.O. i(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I 3 TANK(s)_ X 5234.00 = 5 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 3 Inspections) TANK I.D. 40) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78_0O/hour (3 hours minimus/FACILITY) 5234.00 minimum S <br /> PI INSTALLATION PLAN CHECK (Plan Review 3 Construction Inepec:iens) TANK 1.0. :(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = 5624,00 miniAAm 5 <br /> EREPAIR FEE (Workp(an Review b Construction Inspectiais)_ I TANK I.D. %(s) <br /> Pi TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I TANK(s) X 5234.00 = S <br /> A <br /> ITANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234,00 minimum S <br /> R <br /> ?!PING REPAIR FEE = 578.00/hour (3 hours miniinm/FACILITY) = SZ34.00 minimum I S <br /> NI TRANSFER FEE = 520.00! FEE 220.00 UNAUTHORIZED RELEASEE EVALUATIDN = 278.00/hr ( I 12RELEASEE EVALUATIDH = 578.00/hr ( I I SS <br /> I <br /> S! s0 <br /> CI CONSULTATICN FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr I I I S �- S a <br /> OTAL DUE <br /> FOR OFFICE USE ONLY <br /> SWEEPS R CCMPUTER x LCC CCOE OIST CODE AMOUNT RECEIVED CHECK ;t/CASH I RECEIVED Sy I DATE RECEIVED <br /> S <br /> i a <br />