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SAN JOAOJTN =JNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WCRKSHEET <br /> FACILITY SITE NAIE FACILITY CONTACT NAME <br /> A ?<< e-,7 <br /> I FACILITY ADORES$ -^ SITE PHONE 0 with AREA CODE <br /> L -7y/ S- �/r /L� h, - I 7L2 - sS 0 3 / <br /> I I <br /> T <br /> CITY / / STATE ZIP C.rOE 0 of TANKS <br /> Y 5�L° C,/c /Z VT �i ,�C2� at SITE / <br /> A APPLICANT/BILLING NAVE APPLICANT GNTACT NAMETj <br /> ! <br /> L <br /> I NAILING ADDRESS // APPLICANT PHONE 5 WITH AREA <br /> N I CITY STATE ZIP CODEy STALL CN ` <br /> T /(.f Li � ,:� rl tLCSLRE, fISTALUTi CN, ate. C. /<::>,s <br /> TOTAL <br /> Al <br /> C 1986 1987 1 1988 1 1989 11990 <br /> ANNUAL FACILITY FEE (Prior to Jewry 1, 1991) • 5100.00 <br /> ' IG�Gl! S a <br /> v <br /> TANK FEE • 550.00/7ANK (prior to Jewry 1,1991) 5170/TANK (after January 1, 1991) <br /> F Y Tanks • / 1986 11987 11988 1989 1 1990 1991 1 1992 1 1995 11994 11995 11996 <br /> A (zultiply S by fee for J <br /> C each year applicable) $O' x '� /6'OT/00-r/. ,3Y��3Lto I I S log(-, 0 <br /> I <br /> L <br /> STATE SURCHARGE • $56.00 each TANK (Due every 5 years) See California H S S Code, Section 25237 <br /> T I Y Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> T (enter amount and year) <br /> SCS o� <br /> PERMANENT CLMMS (Removal or Authorized Closure-in-Place I TANK I.D. 0(s) <br /> C <br /> L CLOSURE FEE- • 553.00 per hour (3 hours minion per TANK) I 0 TANK(s) X $159.00 • S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-tim persit, for review/inspections) TANK I.D. 0(s) <br /> R <br /> E TMPCRARY CLOAJRE FEE • 5150.00 each TANK 0 TANK(s) _— X $150.00 • S <br /> P PLAN CHECK (Install. Plan Review i Construction Inspections) I TANK I.D. 0(s) <br /> L <br /> A <br /> A PUN CHECK FEE - 553.00 per hour (8 hours miniaam per Facility) • $424.00 minimuo S <br /> AI REPAIR FEE (workplan review i construction inspections) I TANK I.D. O(s) <br /> c <br /> P TANK REPAIR FEE • SS3.00 per hour (3 hours mini=AV ANX) 0 TANX(s) X $159.00 • S <br /> A <br /> I <br /> A PIPING REPAIR FEE • $53.00 per hour (3 hair miniaxm per facility • 5159.00) S <br /> M TRANSFER FEE • 520.00 UNAUTHCRI ZED RELEASE EVALUATION • 553.00/hr I S <br /> I <br /> S i <br /> C CCNSULTATICH FEE • 553.00/hr SAMPLING INSPECTION FEE • s53.00/hr S <br /> TOTAL DUE S /IJ Uu <br /> OFFICE USE ONLY <br /> i >•[J) i i� TIUICR i f lws�.iJSC• U�]���I N1{.1JI�TAG.0 I �.nC�/W1 I IL'b�l'/C.J Y� I 4JA � RL���YCJ <br /> f��•••Si�R••iat�f••��••i—�Rs••i•1f•�)•ts•�L•L•�•R••IRL•ils••�•`J it••ft Lsfilti��•••�iL•�i•1i <br />