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SAN Ju DSTEL 1C R THtAL I H U l Y L5I0N <br /> WN RGRQJNSTORAGE TANK PR0GRAFEEWOR <br /> FACILITY CONTACT NAME <br /> S FACE ITY SITE NAME 04f1 <br /> I I + <br /> T SITE PHONE # with AREA CODE <br /> E FACILITY ADDRESS }� <br /> b STA E ZIP CODE # of TANKS <br /> CITY ' 4 `I j� at SITE <br /> A —] I } U f j <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITY {Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1487 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> XXX% XX%X XXxX XXXX XXXX $ XxXXXXXXxXXXX <br /> A <br /> C XXX% xxxx XXx% xxxx xxxx S xXxxxxXXxXXXX <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> IS170/TANK (After January 1, 1991) <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) <br /> E1989 1487 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> # Tanks = <br /> F (multiply # -by fee for $ <br /> A each year applicable) XXXX XxXX XXXx XXXX %XXX <br /> $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX xxxx X%XX XXXX <br /> L <br /> ! STATE SURCHARGE = $S6.00 each TANK (Due every 5 years) See Galifornia H b S Code Section 25287 <br /> T 1988 through 1990 1991 through 1446 <br /> Y # Tanks x $56.00 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) <br /> TANK I.D. #(s) <br /> LI # TANK(s) X $234.00 = $ <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /> S TANK I.O. #(s) <br /> U TEMPORARY CLOSURE (Plan Review b inspections} <br /> R $ <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimumlFACILITY} 5234.00 minimum <br /> EA <br /> ECHECK <br /> PLANES78.00/hour <br /> K (Plan Review & Construction Inspections) TANK E.D. #(s) <br /> S624.00 minimum5 <br /> FEEE = (B hours minimum/FACILITY) <br /> R REPAIR FEE (Workplan Review b Construction Inspections) <br /> TANK I.D. #(s) <br /> E # TANK(s) X $'234.00 = S <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /> 5 <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) <br /> It = $234.00 minimum $ <br /> PIPING REPAIR FEE = 578.001hour (3 hours minimum/FACILITY) <br /> A $ -- <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br /> I <br /> S = S78.00/hr S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE <br /> FOR OFFICE <br /> USE ONLY <br /> _.............._... _.::::--::::::::.---..............::::::::::-:,. <br /> ::::::::::::: :::::::::::::::::: .........::::::::::::::: ::::::_:::: .:;:::::e::::::::: .............:.._.._.._.._.e......_........ ..._ .._.. DATERECEIVED <br /> NT RECEIVED CHECK #/CASH RECEIVED (;Y <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT <br /> Cn j <br /> ........................�:::::::::::::: <br /> L.................... _..... <br /> H:M <br /> ::::::::::::::::::_::::::::::::........:;...... ......... <br />