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SAN JOACX% PUBLIC HEALTH SERVICES - E)MRONIIENTAL TH DIVISION <br /> • STORAGE TANK PROGRAM - FEE WRKSH <br /> S FACILITY SITE NAME /, / I FACILITY CONTACT NAME <br /> I <br /> T <br /> E FACILITY ADDRESS I ZTE Pwith AREA CODE <br /> CITY7ATEIC/Mb I of TANKS <br /> A II at SITE <br /> P <br /> P APPLICANT/S LIN N I APPLI CONTACT NAME <br /> L C� <br /> I <br /> C MAILING DRESS f APPLICANT PHONE VITHAR C04 <br /> A <br /> li <br /> T CITY �ATEI 701/'01 <br /> TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> Toru <br /> 1986 i 1987 � 1988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A xxxx =a I =a =a rm S XXX0000axxxx <br /> C- <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I xxxx I xxxx I =a I =cc xxxx S )CDOOCC{X)O(XXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) I S!70/TANK (After January 1, 1991) <br /> E <br /> T Tanks = 1986 j 1987 ` 1988 ( 1989 j 1990 11991 ` 1942 11993 � 1994 j 1995 11996 <br /> F (miltipty : by fee for <br /> Al each year applicable) x= I xxxx I r-= I xxxx I )()= I I I ( S <br /> 11 TANK PENALTY FEES ASSESSED I =(X j xxa I xxxx )0= j xxxx <br /> L <br /> II STATE SURCHARGE = 556.00 eats TANK (Due every 5 years) See California 1 & S Code, Section 73287 <br /> T <br /> T 1 Tanks x 556.00 I 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> Cj PERMANE14T CLOSURE (Removal or Authorized Closure-in-Place) j TANK I.D. 1(s) <br /> L I _ <br /> OI CLOSURE Fc_ = S78.00/hour (3 hours minimua/TANK) TANK(s) X 5234.00 - S <br /> S <br /> U+ TEMPORARY CLOSURE (Plan Review & Insrections) TANK I.D. .(s) <br /> R <br /> Ej TE%4PCRARY CLOSURE FEE = S78_00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> Pj !NSTALLATION PLAN CHECK (Ptan Review b Const action Inspections)' TANK l.D. w"(s) <br /> L <br /> Al <br /> Yl PIAN CIE_: Fc= = S78.00/hour (8 hours minim:a/FACILITY) = S624.00 minimum S <br /> Rj REPAIR Fc= (Workplan Review & Construction Inspections) I TANK 1.0. x(s) <br /> = IPI TANK LINING REPAIR Fc= = S78.00/hour (3 hours minimm/TANK) I TANK(s) X SZ34.00 = S <br /> A <br /> 1 TANK RETROFIT REPAIR FE= = S78.00/hour (3 hours min./FACILITY) = S234.00 minimuu S <br /> z <br /> PIPING RE.°AIR FEE = 578.00/hour (3 noun minimum/FACILITY) = SZ34.00 minimum I S �d <br /> M TRANSFER F'== = 520.00 ( I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I I S <br /> I I i <br /> S' <br /> Cl CONSULTATION F= = S78.00/hr I I SAMPLING INSPECTION FEE = S78.00/hr I S <br /> TOTAL DUE s 2-3$. 001 <br /> FAR OFFICE USE ONLY — <br /> GiT <br /> SWEEPS 3 I COMPUTER '+ j LOC CODE I DIST (CAE I AMOUNT RECEIVED CHECK --/CASH I REZEIVED 3Y I DATE aEr^T VED <br /> � S I I - <br />