Laserfiche WebLink
` IN caMOLLIC HEALTH SERVICES - ENVIRONMENTAL HFJIL�IW ON <br /> SAN JOAOI! UitDERGR(X1MD STORAGE TAIiK PROGRAM FEE y0R1CSHEE7 <br /> FACILITY CONTACT NAME <br /> S FACILITY SITE NAME r / __ <br /> I ft,( _ <br /> T SITE HOME � ith AREA CODE 2� <br /> E FACIL TY ADDRESS r, 6 &r �� , <br /> L L- ATE 2IP CODE # of TANKS <br /> CITY ' at SITE <br /> A <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L < �y y v2� sEJ CLQ( <br /> I - APPLICANT PHONE # WITH AREA CODE <br /> C NAILING ADDRESS <br /> ATYPE of APPLICATION <br /> N STATE ZIP CODE (Closure, Installation, etc.) <br /> T CITY <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> , 1991) 5100.00 xxx)( )0= 'f, l v o- o 1 ' s. <br /> ANNUAL FACILITY FEE (Prior to January t <br /> A <br /> C XX)O( I =(X Gy D 100 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable! 5174/7ANK (After January 1, 1441) <br /> V TANK FEE <br /> I 1 1991) <br /> 550.00/TANK (Friar to January , <br /> E 1986 1987 1488 1989 1940 1 1991 11992 1993 1994 1995. 1996 <br /> N Tanks _ <br /> F (muktipiY x by fes for xx)o( XXXX �(}' ! �; -3't0 <br /> A each year appkicable) <br /> C <br /> I TANK PENALTY FEES ASSESSED <br /> L = $56.00 each TANK (Due every 5 Years) See California H d� S Code, Section 25287 <br /> I STATE SURCHARGE <br /> T 1983 through 1990 1991 through 199b <br /> T # Tanks x 556.00 S `.ry <br /> (Enter amount and year) <br /> t <br /> TANK I.O. #(S) <br /> C pERMAHENT CLOSURE (Removal or Authorized Closure-in-Place) U G� <br /> L � TANK(5) .�' X 5234.00 <br /> O CLOSURE FEE = S78.00/hour (3 hours minimLWTANK) <br /> S TANK I.J. l(S) <br /> U TEMPORARY CLOSURE (Ptan Review $ Inspections) <br /> R <br /> E TEMpt)RARY CLOSURE F€E = 578.00/hour (3 hours minias,m/FACILI7Y) 1 5234.00 minimum <br /> p� INSTALLATION PLAN CHECK (Plan Review $ Construction Inspections) TANK I.B. l(s) <br /> L S <br /> A 5624.00 minimus <br /> >i PLAN CHECK FEE = 578.00/hour (8 hours ainimun/FACILITY) <br /> tions) TANK I.J. 4(5) <br /> R REPAIR FEE (yorkpian Review g Construction inspec � 5 <br /> E X S234.00 <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimimlTAHK) TANK(s) S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br /> R = 5234.00 minimus 5 <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br /> = 520.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br /> M TRANSFER FEE <br /> 4 <br /> 3 <br /> I <br /> I ; <br /> SSAMPLING INSPECTION FEE = 578.130/hr <br /> C CONSULTATION FEE = S78.00/hr p f, <br /> TOTAL DUE ; _ ? <br /> FOR OFFICE USE ONLY DATE RECEIVED -_ <br /> '— SUEEPS COMPUTER $ LOC CODE DIST CODE I AMCUNT RECEIVED ' CHECK /CASH I RECEIVED SY <br /> S _ - <br /> Page 11 <br /> EH 23 032 (REVISED 10-28-93) <br />