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r SAN JOASCOUNTY PUBLIC HEALTH SERVICES- ENVIRONMES HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE UORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T SITE PHONE # with AREA CODE <br /> E FACILITY ADDRESS <br /> A STATE ZIP CODE # of TANKS <br /> A CITY Vn 07 (A la-��p:Izj at SITE <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N STATE ZIP CODE TYPE of APPLICATION " <br /> T CITY (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior [o January 1, 1991) = $100.00 XX%x XXXx xxxx xxxx xxxx % xxxxxxxxxx%xx <br /> A <br /> C xxxx xxxx xxxx xxxx xxxx S xxxxxxxxxxxxx <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> V TANK FEE 550.00/TANK (Prior to January ry 1,1991) 5170/TANK (After January 1, 1991) '�(!fS�'1m'1$l� 9� <br /> E 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> # Tanks = I <br /> F (mut tiPly # by fee for 17 p. <br /> A each year applicable) xxxx xxxx xxxx X%%% x%xX r"16 f7U f70 17v 17G S /O ZO DO <br /> G I'Im ( 6 8Tu f7U )'7G S' )OZb <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx xxxx xxxx xxx% <br /> L <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California N 8 S Code, Section 2528 <br /> T 1988 through 1990 1991 through 1996 7 <br /> Y # Tanks 1 x 556.00 <br /> (Enter amount and year) S <br /> --� Ct^=nre-in-Ptace) TANK I.D. #(s) <br /> C PERMANENT C �Ioe4, ^` <br /> L 1 # TANK(S)_ X $234.00 S <br /> 5 CLOSURE FEE �d <br /> U TEMPORARY I �'Gic`f7 rg'OG�+c•/'Y-�'�' �r� TANK I.D. #(s) <br /> It 7;14,J1-5 S <br /> E TEMPORARY 'Y) 5234.00 minimum <br /> EP ons) TANK I.D. #(s) <br /> $624.00 minilmm <br /> R REPAIR FE FTAN7KI.D. #(s) <br /> E TANK(s) X $234.00 S <br /> P TANK LIN) <br /> A ITY) = S234.00 minim!m S <br /> 1 TANK RETI <br /> N I = S234.00 minirm S <br /> PIPING R <br /> M TRANSFER FEE <br /> = 420.00 uanv r::v...�__ EVALUATION = 578.00/hr S <br /> I <br /> S . <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE 578.00/hr <br /> TOTAL <br /> FOR OFFICE <br /> USE ONLY <br /> ......... .. :::::: : ::: . .::::• : :::�! n!n!!!!!e!an!!!n!!n^.mmnm!nen!mm�nnumrnmc;ynumnnnnl.m .,, . <br /> nqllum' <br /> :!!ErnR.!n�#�a!!!n!!LnoOoCn!nnCnOmD;!nEn:nWWn:D:nnI aS;ainneCmO!!DciE;!m;nnnAnMnnOnU!nN!!!TnnuRWE!!nCipEnnInVeE'!"D! CHECK #/CASH nnnna.RECEmIV!!!:EnmD arnunnnnn!,n!!nunnnmmDA�!mTmE rnRuaEmCnEn!eInVoEmD.n <br /> nenww!�� <br /> Ei.11l!rill <br /> . . ..... .. ._ :::::::::::::::• :: :::!!al!!:.^.!n!nnnn!!!n!annna!m!uI!mn! •^r.Cann!n!nr.!!n!!c!:I!in!nn.!n!a!n:n!!!!!nu!mgnnnpc!!!!!!nnunm!lliiiliiiiinnmm� <br /> !!n!:!nin!!r!nenfin!e!!!iinn;!!nr!!!!fiA!n!!!Win!nna!!!!n!I!!!!Innr1!!!!!!!nnna!mmn! !un!n!unm0!!ullamin!nnmummnnlmm�n!:Im!!minnnnmmnnn!:!mm�nnan.nm <br />