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SAN JOAOUI6,AMTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL tLTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WRKSNEEY <br /> ` FACIL TY SITE NAME �� FACILITY CONTAC NAME�� <br /> E FACILITY ADDRESS SITE PHONE # i AREA CODE <br /> WE Ma <br /> CITY�\J O STA E ZIP CmE # of TANKS <br /> AV!W at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTA NAME <br /> L `J} <br /> I <br /> CMAILING ADDRESS APPLICANT PHONE WITH AREA CODE <br /> A - <br /> T CITY STATEi ZIP CODE TYPE of APPLICATION <br /> (CLasure, Installation, tc.) 16011, <br /> TOTAL <br /> 1986 1 1987 11988 1 198 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A X%X% XXXX I %XXX'6�4&x XXXX S XX%XXXXX%XXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX xxxx xxxx xxxx S %XXXXXXXX)O%X <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (Af January 1, 1991) <br /> E <br /> 9 Tanks 1986 1987 1988 1989 11990 1991 11992 993 1 1994 1 1995 1996 <br /> LAeach <br /> tiply 773y-fee for ITU D ol �7L <br /> year appl Noabl e) X)OX XXXX XXX% X)OIX XXXX / 5 PENALTY FEES ASSESSED XX)( XXXX %x%x XXXX xxxx , ' D '7o fE SURCHARGE = $56.00 each TANK (Due every 5 years) See fornia N a S Code, Section 25287 <br /> nks x 556.00 1988 through 1990 1991 through 1996 <br /> er amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-i VFace) I TANK I.O. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TA N i # TANK(s)_ X $234.00 = S <br /> 5 <br /> U TEMPORARY CLOSURE (Plan Review a Inspections I TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 ho minimue/FACILITT) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review Canstruction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PIAN CHECK FEE = 578.00/hour (8 A minimum/FACILITY) 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review onstruction Inspections) I TANK 1.0. #(s) <br /> E <br /> P TANK LINING REPAIR FEE _ .00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FE = S78.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE _ .00/hour (3 hours minimm/FACILITY) = S234.00 minimum S <br /> N TRANSFER FEE $20.00 I UNAUTHORIZED RELEASE EVALUATION - S78.00/hr S <br /> 1 <br /> S <br /> C CONSULTATION F = S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr I ; <br /> TOTAL WE <br /> FOR OFFICE U LT <br /> _�—SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED I CHECK */CASH RECEIVED BY DATE RECEIVED <br /> I. _.. .. <br />