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SAN 1C.AWIN COUNTY PUBLIC HEALTH SZ4VtC~S - EYVtRCNMENTAL HEALirt 0(YS[CA <br /> UxpERQcLDm STC:RA E TANK PRC GR M - FEE 'SHE=— <br /> FAC:L:TY C=NTAC7 NAME <br /> S' =AC:L[nTY SITES NAME <br /> T' SITE ?HONE + -aith AREA COLE <br /> 'El FACILITY AOORESS <br /> FSTATEZIP C=E or TANKSA `A `�, rt d /1`j I I at SITE <br /> P /+ 1 j APPLICANT pCZXTACT bNAME <br /> APP'_tCANT/SILLING NAME gam/ jr APPLI <br /> Q%jr <br /> I APPLICANT ?HCNE '+ WITH AREA ("...OE <br /> C' MA(Lt4G AOORESS I C-�O-I) I(Db to(p <br /> �� 113 wt�Dov�t� I � <br /> STATE ZIP C Jit I YPE a4 APPLICATION <br /> T` CITY ��^LUMA 6A '"'!! L� I{ CCLcsure, tnstaL(at.on, etc-3 <br /> ` tr TOTAL <br /> 1986 i 1987 1988 f 1989 1990 <br /> ANNUAL FACILITY FEE (P,-ior to January 1, 1991) = 5100.00 { ! <br /> xxxx I xxxx xxxx ` xxxx ` xxxx i-s xxxxxxxx <br /> A <br /> C, Licable) I XXXX xxxx xxxx xxxx j XXXX 5 xxxxxXXX <br /> T� FACILITY P=_NALTY FEES ASSESSED C[. app <br /> Ii 1441) I S,70/TANK (After January <br /> uar1, 1941) <br /> V TANK FEE = 550.00/TANK (Prior to lany <br /> c = 11488 1989 ( 1990 ` 1991 1992 ` 1993 ( 1944 ` 1995 1996 ` 1997 11998 <br /> ranks <br /> 'r (muLtipLy w by Pee Por s D <br /> A each year applicable) xxxx I XXXX I XXXX I XXXX XXXX j ' I 3 <br /> IS <br /> ( TANK PENALTY FEES ASSESSED i xxxx ! xxxx ` xxxx ! xxxx 'xxxx <br /> I <br /> L. 5 <br /> ( STATE SURCHARGE FOR NEr.J FAC:L[TIES GNLT=518.ZD I <br /> T1988 :hrcu;n 1993 (556) 1993 chraugh 1997 C556)� ,998 <br /> Y � Tanks x 53.00 s <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX <br /> CL II TANK E.G. -(s) <br /> C! ?ERMANEHT CLOSURE (Removal or Authorized csure-;n-PLace) i - <br /> L! j X SZ34..00 - S <br /> c -- - 578.00/hour (3 hours njninzm/TANK) = TANK<sl <br /> OI CLOSURE Fcc - ' <br /> S' I TANK I.D. »(S) i <br /> UI TEMPORARY CLOSURE (?Lan Review 3 tnspecticn`sl f { <br /> R c -== = s78.00/hour (3 hours ninirxn/FACILITY} j 5234.00 minims s I <br /> E TEMPORARY CLOSURE ,c= <br /> ?� INSTALLATEON PLAN CHECK (?Lan Review 3 Ccnszr cion tnspec:icns)j TANK E.O. +'Csl <br /> i <br /> A c I = S624.00 minimus 5 i <br /> N ?LAN CHECK FEE = 578.00/hour (8 hcurs minimr�+l.ACIL.TY) <br /> FA <br /> REPAIR : (Workplan Review 3 Construction Inspections) I TANK 1.0. d(s) <br /> i T TANK(s) X 5234.00 = S <br /> 78.00/hour (3 hours minimum/TANK) <br /> = 5234.00 minisnssOFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br /> Rr = 5234.00 minircm S <br /> ?IPtNG REPAIR FEE = 578.00/hour (3 hours minium/FACIL.TY) <br /> MI TRANSFER FEE = SMOG � � UNAUTHCRIZ_'D RELEASE E`JALUATtGV = S78.00/hr <br /> 5 j <br /> S. _ <br /> Cl CONSULTATION fc = 578.00/hr ' ` AMPLING C4SPECTICH F'== = 578.00/hr <br /> - S <br /> I r <br /> TOTAL CUE S 'f S 2,? I <br /> ECR OFFICE USE ONLY --- — -- <br /> REOC-INFO 3T ( OATS 2E�tVE7 - <br /> S1JE:?S I COMPUTER ;tI LOC CSE 0(ST CODE i AMQINT RECcIVEO I CHECK -/CASH <br /> ?H 23 032 (REVISED 1-12-98) <br />