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SAN lOAOUtN (STORAGE TANKVPROGRAMENVIFES WCRKSHE*DIVSION <br /> GRCUxD SI FACILI/iY SITE NAME FAC}L�CONPCT NAME <br /> � �-. f/^ JYl_� Lam" <br /> T I l C l / l ✓,M��I1 <br /> I SITE PHONE x with AREA C E <br /> S FACILITY ADDREA <br /> s �Ls� <br /> CITY I STATEI ZIP CODE k of TANKS <br /> A cL <br /> at SITE <br /> ^ <br /> , <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/8I 4G NAME <br /> L <br /> I I APPLICANT PHONE 9 WITH AREA C E <br /> C MAILI G ADDRESS0 <br /> A (�. L 744 <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITY (Closure, installation, etc.) <br /> TOTAL <br /> 1986 11987 11988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior :o January 1, 1991) = 5100.00 XXXX X%XX I �0 /LJU <br /> A <br /> C I XXXX I XXXX )o I I Ui f e)t7 <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) y <br /> I5170/TANK (After January 1, 1991) <br /> VI TANK FEE = S50.00/TANK (Prior to January 1,1991) <br /> E d Tanks = �Q_ 1986 11987 1988 11989 11990 l 1991 1992 11993 11994 11995 11996 <br /> F (multiply 7 by fee far 5`�2 <br /> A each year applicable) XXX% XXXX � ,2� ��Oze� ��1/0'?-01�0 <br /> G' 3dz7 V,zZ'0 /0-w /nm I S 36 6 0 <br /> I TANK PENALTY FEES ASSESSED I XXXX X%XX I �p 13�� I � <br /> L� r Section 25287 <br /> I� STATE SURCHARGE = S56.00 each TANK (Due every 3 years) See California H 3 S ode, <br /> T' <br /> 988 through 1990 1991 through 1996 <br /> YI d Tanks x 156.00 1 <br /> t (Enter amount and year) z L (477— <br /> C <br /> 47 Z. <br /> C� PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) <br /> TANK 1.0. N(s) <br /> L9 TANK(s)_ X 5234.90 = f C) <br /> OCLOSURE FEE = S78.00/hour (3 hours �ninim.m/TANK) <br /> III TANK LD. Y(s) <br /> U TEMPORARY CLOSURE (Plan Review 3 Inspections) <br /> R f <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) 3234.00 minimus <br /> PI INSTALLATION PIAN CHECK (plan Review $ Construction Inspections)I TANK 1.0. f(s) <br /> L <br /> A - S624.00 minimus f <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimMFACILITY) <br /> RI REPAIR FEE (Workplan Review 3 Construction Inspections) TANK I.D. �(s) <br /> E. Mms <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minim miTANK) TANK(s) X A I TANK RE7ROF[T REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 5234.00 mininamR = S234.00 minimm <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimm/FACILITY) <br /> M) TRANSFER FEE <br /> = SZO.OG I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I S <br /> S <br /> CI CONSULTATION FEE = MACAW I SAMPLING INSPECTION FEE 578.00/hr <br /> TOTAL DUE S �j <br /> FOR OFFICE USE ONLY <br /> SWEEPS X COMPUTER LOC .ODE I DIST CODE AMOUNT RECEIVED CHECK -/CASH REC`°IVEO 3Y DATE REC'c LVED <br /> I <br /> EH 23 032 (REVISED 10-28.93) <br />