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• • <br /> SAN JOADU IN UCOUNTY NDERGROUND STORAGENTANKVICES -PRROGRAK - FEE 40RNHEALTH DIVSIOM <br /> KSHE <br /> FACILITY CONTACT NAME <br /> S FACILITY SITE NAMEQd� <br /> I <br /> 1 SITE PH E # with AREA CODE <br /> FACILITY ADDRESS <br /> —2- <br /> L <br /> STATE ZIP CODE I If of TANKS p00 G4LC-O <br /> CITY . \ �A 9� at 517E—0 S✓ <br /> A UG �'v (� APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME FLp"S <br /> t �S �AnD N APPLICANT PHONE # 41T AREA CODE <br /> C (LING ADDRESS �� 2�9 �� 3�J <br /> N `Q' STATE ZIP CODE TYPE of APPLICATION �TAA1K- <br /> 7 CITY 1 //(. (���5 (Closure, Installati an, etc.) <br /> N e-Al TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 $ <br /> A f <br /> Cxxxx xxxx <br /> I FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> 1 5170/TANK (After January 1, 1991) <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) <br /> E 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> # Tanks <br /> F C,;ultip(y # by fee for i $ '120-00 <br /> A each year applicable) $ - <br /> C <br /> 4TANK PENALTY FEES ASSESSED xxxx xxxx <br /> L <br /> See California H 6 S Cade, Section 25 <br /> 287 <br /> 1 STATE SURCHARGE • $56.00 each TANK (Due every 5 years) <br /> T 1986 through 1990 1991 through 1996 <br /> y # Tanks_ x $56.00 $ <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) $ <br /> It $234.00 • r <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimMTANK) <br /> STANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review 6 Inspections) $ <br /> R # TANK(s)__ x $234.00 <br /> E TEMPORARY CLOSURE FEE • $78.00/hour (3 hours minimus/TANK) <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L $ <br /> A $624.00 minimum <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimus/FACILITY) <br /> R REPAIR FEE (Workplan Review 6 Construction Inspections) TANK I.D. #(a) $ <br /> E x $234.00 <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimuNTANK) # TANK(e) $ <br /> A <br /> 1 TANK RETROFIT REPAIR FEE • 978.00/hour (3 hours min./FACILITY) $234.00 min nun $ <br /> p - $234.00 minimum <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br /> N TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION <br /> . $78.00/hr $ <br /> I <br /> S $78.00/hr $ <br /> C CONSULTATION FEE $78.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE $ <br /> A OFFICE USE ONLY , m n !xn;rwl L wm 0°Eidn�!! !n uw <br /> unr!msml�!;;�unaq m::!nnwnw!m!p:mmn�mm;:ManmM!!!!,nrxn�;�lMINF!y'Ru� d ,y n <br /> MMM <br /> ii edFx!uhnnnn!,,,!u umi,t�x Yal!w:NUJL..mmm a1 ItM0. !!�!n I it u i nn ml x!wumun <br /> IT SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED H /CASH RECEIVED 8Y DATE RECEIVED <br /> 10 _ �'`' a m3 mL ue mg nammw C� / / y m <br /> u::m! m mlZ;!I::r:.mm�e::l III-I, :!, ewmu o u u�b uPw mnu u <br /> �mm,. s rnl �-nnumdlm�a!ue <br /> !VLLmmw�Jm:mVLW!i!IL�m�!miwma <br /> Pegs 11 <br /> EH 23 032 (REVISED 11-1.92) <br />