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SAN JOARIIIH COUNTY PUBLIC HEALTH SERVICES - EMVIRMMENTAL HEALTH DIVISION <br /> UUDjjbUlWO STORAGE TANK PROGRAM - FEE "MEET <br /> S FACILITY SITE NAME qq ��!! I FA TY CON�A <br /> I — (. A /UTAi INC W <br /> E FACILITY ADDRESS I SITE PHONE # with AREA CODE <br /> D ,1;7, i 6 5 <br /> & SS77 Tc ZIP CODE # of TANKS <br /> CITY G 0?3 at SITE <br /> A �7 <br /> P AP PL CANT OD TACT NAME <br /> P APPLICANT/BILLING NAME /)O <br /> L (c <br /> I P !CANT PI(ONE # WIT EA CODE 30 CQ <br /> C MAILING ADDRESS _ U— -�lo _M,� . 1(1'10 f\Ck <br /> A 6 iiJJJJ <br /> M STA E ZIP CODE TYPE of APPLICATION <br /> T CITY 1 ., lil q (Closure, InstaLtation, etc.) <br /> IfJ TaTAL <br /> 1986 11987 11988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 XXXX =a I X= I rom I XXXX S =mCcoOC(XXX <br /> A <br /> C I == I XXXX I XXXX =C( I r-= 5 XXXXXXXXXXXXX <br /> T FACILITY PENALTY FEES ASSESSED (If ApplicabLe) <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170RA99 (After January 9 1991) <br /> E 1986 11987 11988 11989 i 1990 1991 11992 1993 11994 11995 11996 <br /> # Tanks = <br /> "r (multiply # by fee for 5 <br /> A each year appLJCable) XXXX I XXXX I XXXX I XXX% I XXX)C I I I I I <br /> C 5 <br /> I TANK PENALTY FEES ASSESSED I XX)L\ I XX)0( XXX)( I XXXX I %XXX I <br /> L <br /> I STATE SURCHARGE = S96.00 each TANK (Due every 5 years) See California X & S Code, Section 25287 <br /> T <br /> Y # Tanks_ z 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L I # TANK(s)_ X 5234.00 = S <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimm/TANK) <br /> S & I TANK [.0. #(S) <br /> U TEMPORARY CLOSURE (Plan Review Inspections) <br /> RS <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours mlinimXO/FACILITY) $234.00 minimum <br /> PI IHSiALLATi ON PLAN CHECK (Ptah Review & Comtruc.ion Insoec:ians)I TANK I.D. #(s) <br /> L <br /> A = S624.00 minimum S <br /> N IPLAN CHECK FEE = S78.00/hour (8 hours miniaaan/FACILITY) <br /> R REPAIR FEE (Workplan Review & ConstrUCtimn Inspections) I TANK [.D. #(s) <br /> EI s <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours mini TANK) I # TANK(s) _ X 5234.00 = <br /> A S 7 <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = R34.00 minimum <br /> R = 5234.00 minimum I S <br /> PIPING REPAIR FEE 578.00/hour (3 hours minimum/FACILITY) <br /> M TRANSFER FEE : 520.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I I I s <br /> I <br /> S I I s <br /> C CONSULTATION FE = 578.00/hr I SAMPLING INSPECTION FE = S78.00/hr <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> r VEp <br /> S41EEP5 9 COMPUTER X LOC CODE DISC CSE i u+wni n-C_:rui � C.,EC+ ,".SM � ^--_• - I = <br /> 5 <br />