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SAN JOAODUN COUNTY PUBLIC HEALTH SERVICES - EMVIRONAENTAL HEALTH n(VSICN D <br /> UNDET NO STORAGE TANK PROGRAM - FEE WRKSHEET <br /> SFACILITY SITE NAM �+ FACILITY CONTACT NAME <br /> T StA77� ?yl - I�. F9 i n e <br /> E FACILITY ADDRESS ^ �) SITE PHONE ! with AREA CCOE cj <br /> i /g/ <br /> A <br /> CITY� ` STATE ZIP� n� atof SITEN� <br /> P APPL CANT/BILLING NAME APPLICANT CONTACT E <br /> L c e f R ; L e r n er <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE ! VITN AREA CODE <br /> A YOE. /navl-l. Sf ��oor Cao 5�f to — <br /> i CITY STAT ZIP COME TYPE A/ttlGTid � " <br /> SS40c1�`�� Q� eeVre In tellation, ete.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> AMMIML FACILITY FEE (Prior to Jenwry 1, 19911 • 5100.00 =- <br /> A In 2 /Oo <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (if Applfcabte) )C= XXXX f <br /> t <br /> V TANK FEE • SSMO/TANK (Prior to January 1,1991) SITOfTANK (After January 1, 1991) <br /> E <br /> ! Tanks • 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply t oySy fee for / q <br /> A each year appLicsble) 'Q JO ,jO J70 �70 (0 3G� <br /> C y <br /> t TANK P£NALTY FEES ASSESSED %XXX XXXX 50 0 "(� 170 !!_i S / (1" <br /> L <br /> I STATE SURCHARGE • 156.00 each TANK (Due every 5 yea") See CaLlfornia H L S Code, Section 25287 <br /> r <br /> Y S TankR K 356.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and Year) _ <br /> S� <br /> C PERMAMENT CLOSURE (Removal or Authorized Closure-fr Place) TANK I.D. 1(s) <br /> L <br /> 0 CLCSURE FEE • 578.00/hour (3 hours minfnxVTAMK) I ! TANK(s)�_ X 2234.00 f " <br /> S <br /> U TEMPORARY CLOSURE (Plan Review ; (nspectlorn) TANK I.D. !(s) <br /> R <br /> E TEMPORARY CLOSURE FEE • S78.00/hour (3 hours minimum/FACILITY) • 3234.00 siniasw 3 <br /> P (NSTALLATtd PUN CHECK (Plan Review S Constructlon IrmPections) TANK I.D. !(s) <br /> L <br /> A <br /> N 1 PLAN CHECX FEE • S73.00/hour (8 hours minimm/FACILITT) • S624.00 minimum S <br /> R REPAIR FEE (Vorkplan Review S Construction IrepeCtloro) TANK 1.0. !(s) <br /> E <br /> P TANK LINING REPAIR FEE • 578.00/hour (3 hours mininnVTAMK) ! TANK(s) _ X $234.00 • S <br /> A <br /> I TANK RETROFIT REPAIR FEE • 978.00/hour (3 hours min./FACILITY) • $2.34.00 minimum $ <br /> z <br /> PIPING REPAIR FEE • S78.00/hour (3 hours mininuNFACILITY) $234.00 mini" f <br /> N TRANSFER FEE • 520.00 UMAUTHCR IZED RELEASE EVALUAT(d • 978.00/hr S <br /> l <br /> S <br /> C CONS 7ATid FEE f78.00/hr SAMPLING INSPECTION FEE • S7E.00/hr <br /> a /gyp TOTAL Dl1E <br /> FOR OFFICE USE ONLY 3- 5'-L3 aPM�RP1.J� L ���__ <br /> r��3'Tre�c7 <br /> Tma b�At`1Ji � /h 3 a <br /> r.arrs�r•�rr�rr•sssa:arr�rsr�rr�r�rsarsrr�raears•rr�rarr(s,'r�•arrarr <br /> EN ZS 032 (REVISED 7.1_93) 3—K-- (3 XB <br />