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S" JOAauIN COU PUBLIC HEALTH SERVICES - ExVFRClMEN7AL NT DIVSIDK <br /> LNDL....AODUO STMAGE TAkK PROr-.PAX EE <br /> FACILITY CONTACT NAME <br /> FACILITY SITE NAriE II i Y�� CN�Aci <br /> i i1c� a�vl T-LA l✓� ,fir rf� T �� kc--V l <br /> SITE P"C"" <br /> x with AREA CODE <br /> 'i-E FACILITY ADDRESS mac, - L-(o(o - 5 t9 7, <br /> DoE sau41, Ll�,-oIl <br /> Ir. I STATE ZIP CODE : of TANKS <br /> CITY ��� € CA el577 a � ac SITE <br /> P S ` } APPLICANT CONTACT NAME <br /> APPLICANT/BILLING NAME <br /> APPLICANT PHONE 0 WITH AREA CODE <br /> C MAILING ADDRESS -1 — 4 (o& <br /> r— STA EI ZIP CODE TYPE of APPLICATION ` <br /> CITY rr l I CA 4 c! �ZCJ tD (Ciosure, Installation, e:^.) C`D5V <br /> TOTAL <br /> r I ;986 1987 11983 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 I <br /> it xxxx I xxxx � xxxx � xxxx xxxx s xxxxxxxx <br /> A <br /> r FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> xxxx xxxx xxxx xxxx xxxx s xxxxxxxx <br /> PFSi70/TAYr (After January 1,TANK FEE = 550.00/TANK (Prior to January 1,1991» Yanksi9a81989 1990 1991 1992 1993 1994 1995 1996 1997multiply by fee for I S eech year applicable) xxxx xxxx l xxxx Xxxx !xxxx I I I I 1 <br /> C <br /> T TANK PENAL FEES ASSESSED Xxxx j xXXX xxxx xxxx }XxXX l <br /> L S i <br /> .1 ST <br /> SURCHARGE FOR NEW FACILITIES ONLY= <br /> T ,993 through 1997 (556) `l <br /> �TFSURCEARGE <br /> Tanks x 38.00 1988 through 1493 (556) <br /> IL <br /> FOR 1998 xxxxxxxxxxxxxxxxxxxxxxxxxxX xxxxxxxXxxxXXXxxXXXXXXx l S <br /> r C <br /> PERMANENN CLOSURE (Removal or Au:horize-d C.osux e-in-Place) � TANK (.D. =(s) <br /> L I x 5734.00 S <br /> 0FEE = <br /> � 1 CLOSURE FEE = 578.00/hour (3 hours mini.mrijTANK) TANK(s) <br /> S++ � <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK 1.3. +(s) <br /> R I523�.G0 minimrn <br /> S <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minim n/FAC1LIiY) <br /> x <br /> P INSTALLATION PLAN CHECK (Plan Review & Cvnstruc:ion Insoections)I TANK 1.D. =(s) <br /> L <br /> A5 <br /> ' k PLAN CHECK FEE = 576.00/hour (8 hours minirun/FACILIT7) = 5,624.00 minirr.an 1 <br /> Ft TANK 1.D. =(S) <br /> E REPAIR FEE (Workplan Review & Construction inspections) <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minim am/TANK) <br /> » TANK(s) X 5234.00 = S <br /> A5 <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) - Sc�L.00 mtn�rtrsn <br /> .R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minirun/FACILITY) = 5234.00 minimum 5 <br /> c <br /> } S <br /> H TRANSFER FEE = 520.D0. � � UkAUTHCR(Z£D RELEASE EVALUATION = 578.00/hr 1 <br /> F..I I I I l 1 <br /> S I 4 S <br /> C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTICH FEE = 578.00/hr I 1 <br /> t <br /> TOTAL DUE <br /> OR OFFICE USE QWLT <br /> ....._......._.._..._.._.:::•::-:::::sat:_:c:„:_—._:scr..::::c'�::;-�::::::_._:___-:::__::—::::::_�-:�__,:___��-...`-Vic_:-,-:�,:-:.=-r_�_:c:_=:�-_-=•.__.:nx-�_:::=:n:::;,::-f-_-?"�.�f=-=——^' <br /> SWEEPS CO.MPUTER�» I LOC CODE DIST COLE I AMOUNT RECEIVED CHECK ='/CASH RECEIVED BY I GATE REC=.VED <br /> .0 7� -n3? lzgV1SF.+0 1-12-98) <br />