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SAN JOA00'R COUNTY PUBLIC HEALTH SERVICES - ENVIRONMEM ". HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WC. ET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T � L ? CbzIG I uti [; <br /> E FACILITY ADDRESS SIT PHONE 3 with AREA CODE <br /> s 4'11 OL)' 7�- <br /> C T'{ SJ+1TE ZIP C4D6 N of TANKS <br /> A _L,. `.?A 'i ID at SITE <br /> P 11�� <br /> P AP LIGNT/BILLING NAME APPLICANT CONTACT NAME <br /> f ) ae'er <br /> CMAILING ADOR APPLICANT P ONE N WITH AREA CODE <br /> A - v -Z�ZL <br /> N <br /> T T1 STA[t�E IP CODE PPLICATION <br /> (/ SSG, (Closure Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 7991) = 5100.00 <br /> A )000( XXXX XX(X XXXX S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) X)= XXXX I XXXX XXXX S <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E N Tanks = 1986 1987 1988 1989 1990 1991 1992 11993 11994 11995 1996 <br /> F ((multiply X by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX S <br /> L <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX I I S <br /> L' <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H d S Code, Section 25287 <br /> T <br /> Y 7 Tanks z $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> / Cl PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. *(s) / 2- 3 t{ <br /> JII 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) S TANK(s) X 5234.00 <br /> S S <br /> j , <br /> V U TEMPORARY CLOSURE (Plan Review 3 Inspections) I TANK LD. 4(S) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> PI INSTALLATION PLAN CHECK (Plan Review 3 Construction Inspections) TANK I.O. i(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = S624.00 minimum S <br /> R REPAIR FEE (Workplan Review i Construction Inspections) TANK I.O. S(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimu /TANK) I N TANK(s) X 5234.00 = S <br /> A <br /> t TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) 5234.00 minimm S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 378.00/hr I S <br /> TOTAL DUE S `13(Q.DO <br /> FOR OFFICE USE ONLY <br /> —_==sew.=.; __' — _ =[r__�—_-_[[___-_--___ _- —:_:._.:-__-_:___::::_:_:_:___::::;:._ <br /> SWEEPS 3 I COMPUTER X -OC CODE DIST CODE AMOUNT RECEIVED CHECK :/CASH I RECEIVED BY DATE RECEIVED <br /> I S <br /> EH 23 032 (REVISED 4-6-95) <br />