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SAN JUAWIN LOUNIT MULIC HEALTH 5ERVILh5 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UW 'ROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAVE FACILITY CONTACT NAME <br /> SIGU�t 2c(u�/ti �Iq�C Si�v� <br /> C <br /> 1 FACILITY ADDRESS SITE PHONE S with AREA CODE <br /> T CITY ..y f ATE 21P CODE / of TANKS <br /> Y r&CA'C , �'/1�� �Ar e? / at SITE <br /> A APPLICANT/BILLING NAME - JAPPLICAMT CONTACT NAME <br /> P i— <br /> P CMGp /L( /GP/N <br /> L <br /> I NAILING ADDRESS N�70 APPLICANT PHONE / WITH AREA CODE <br /> C <br /> 43/ lJ. r( jLD 209 S2� • r1bS3 <br /> A <br /> N CITY S ATE ZIP CODE TYPE of APPLICATION t7 <br /> T �Q✓D CiS7O �' S 3 CLOSURE, INSTALLATION, etc. MC-01OUA �— <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to Jarwary 1, 1991) • $100.00 <br /> I S <br /> V <br /> E TANK FEE $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F Y Tanks . 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply a by fee for <br /> C each year applicable) $ <br /> I — <br /> L STATE SURCHARGE • 556.00 each TANK (Due every 5 yearn) See California H d S Code, Section 25287 <br /> I <br /> T Y Tanks A $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter arrant and year) <br /> f <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. M(s) <br /> C <br /> L CLOSURE FEE • $53.00 per hour (3 hours minimum per TANK) Y TANK(s) X $159.00 f 0 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/Inspectiore) TANK I.D. !(s) <br /> R <br /> E TEMPORARY CLOSURE FEE • $150.00 each TANK k 'ANK(S) X $150.00 • S <br /> P PUN CHECK (Ireteit. Pian Review i Construction Irepectfona) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 553.00 per hour (8 hours minimum per Facility) • $424.00 minimum f <br /> R REPAIR FEE (workplan review d construction fnspecti ors) TANK I.D. M(a) <br /> E <br /> P TANK REPAIR FEE • $53.00 per hour (3 hours minimum/TANK) 0 TANK(S) X $159.00 • S <br /> A -- <br /> I <br /> R PIPING REPAIR FEE • 553.00 per hour (3 hour minimum per facility • $159.00) $ <br /> N CCNSULTAT I0N5 UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> 5 <br /> C fEE • $53.00/hr FEE • 353.00/hr FEE • S 53.00/hr <br /> TOTAL DUE $ QO <br /> OFFICE USE ONLY <br /> rw••++•••w•+a•w••irar4.riwww.r,." ...................._...................................._ ......_................_ ................._ _ <br /> �.r r••r iw.r..a,.»r...ie,naw r'a•,N„4wr aw x„n aw r it•w w...iio www•w r wwr ww i in,rw�tA.m.�.{.y..{,......�...N.a...e.A..w...�..... <br /> wSC�EE�SARi w I� �� w ��1� ��.���� �rCi�raww AUAIE N�EIVEU awaf <br /> e f a <br /> • _ s <br /> ae...rr,rwiwwwarrwrawwriwrwwrirwiwwwr�wwrrwww�wrxwwww�wwwrrw wwwwwwwiiirwiwwrwi"rrwwi."a:..••• s <br /> wwwawwswrwwwawwwwwawwawwawrwwwwwwwwwwrwawwswwwawwsewwwawwmaOwaemlwAwwaasiwwwsmw ler <br /> EN 23 032 (RIE1f 1/10/911 ft Pace 11 <br />