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' SAN JOApIJIN COUNTY PtZLLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UImERGRCL= STORAGE TANK PROGRAM FEE WORKSHEET <br /> IFACILITY S T MAM9G FAT ACT NAME <br /> Te ' SITE PRONE # with AREA CODE <br /> E FAC4AD .S <br /> i ST TE ZIP CODE # of TANKS <br /> C1 ac SITE <br /> P APPLl T TACT E <br /> P <br /> pop T/BILLING NAME�+ � T <br /> L tf <br /> t <br /> IAPPLICANT 7E # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N 5 TE <br /> TCITY ZIP CODE - PLICATION <br /> I ^ . <br /> C� losure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 11988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 I = <br /> A )0= p°°( <br /> D <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XIOIX I tool s <br /> I <br /> 1991) <br /> V TANK FEE = 550.00/TANK (Prior to January 111991) 5170/TANK (After January 1, <br /> E <br /> #.Tanks = TV <br /> 1986 1987 11988 11989 11990 11991 11992 11993 11994 1995 1996 <br /> F (multiply # Sy fee for <br /> A each year applicable) XXX)( I XXXX I I I I I I I I S <br /> C' <br /> 1 TANK PENALTY FEES ASSESSED I XXXX X)OX I I I I S <br /> L <br /> 11 STATE SURCHARGE - 556.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25287 <br /> T' <br /> TId Tanks_ z 556.00 1988 through 1990 1991 through 1996 <br /> (Enter unand 5 p, <br /> C PERMANENT CLOSURE (Removal or Authorized Ctosurr in-Place) TANK I.D. #(s) <br /> L <br /> CLOSURE FEE = 578.00/hour (3 hours minima/TANK) # TANK(s)_ X $234.00 = S <br /> 0 <br /> U TEMPORARY CLOSURE (Plan Review S Inspec:iau) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 iours minimum/FACILITY) $234.00 minimum S <br /> PI INSTALLATION PLAN CHECK (Plan Review 3 :astruction Inspections) TANK I.O. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 578.00/hour (8 hours ainim.WFACILITY) = 5624.00 minimum s <br /> IIREPAIR FEE (Uorkplan Review 3 Construction Inspections) TANK I.O. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 Sours mininWTANK) I # TANK(s) _ X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) = 5234.00 minimus S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours ainimLm/FACILITY) = 5234.00 minimum S <br /> MI TRANSFER FEE = 520.00 I I UNAUTHORIZED RELEASE EVALUATION - 578.00/hr I I S <br /> SCONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE - 578.00/hr I S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> SLEEPS d COMPUTER J LOC CODE DIST CCDE AMOUNT RECEIVED CHECK :/CASH RECEIVED 3Y DATE .RECEIVED a <br /> � S <br /> EH 23 032 (REVISED 10-28-93) 3 <br />