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SAN JOAaUTY PUBLIC HEALTH SERVICES - ENVIRONMENT LTR OIVSION <br /> ERGROUND STORAGE TANK PROGRAM - FEE WORK <br /> I FACILITY SITE NAME _ r. ��/ FAC�TY CONTACT NAME <br /> � . J "J- a <br /> T sM PHONE X with AREA CODE <br /> -E FACILITY ADDRESS, _ 3 O <br /> & CL /J• STATE ZIP CME <br /> k of TANKS <br /> A CITY ./l_p�1�y`G` C 7!. �5 at SITE <br /> P /`// ( APPI[CANT CONTACT NAME <br /> P APPLICANT/8 CLING NAME /J � j�/��r/•1 <br /> L L / /f/1f �( /� Z (� /1 <br /> I APPLICANT(�P' ONE 1 WITH AREA CODE <br /> A NAILING ADDRESS Sgy- .3"), 6�� 3� 00 <br /> N O IC <br /> � <br /> T CITY Q 5_T�E ZIP 0003 TYPE of APPLICATION�� (Closure, Installation, etc.) <br /> l TOTAL <br /> 1986 1987 11988 1989 1 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100-00 XXXX xxxx X)= XXXX XXXX s XXXXXX)tX <br /> A <br /> CX)= 1 xxxx )O= xx— xxxx s xxxxxx x <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) <br /> E 1988 1989 1990 1991 1 1992 1993`1 1951 1 1994' 1998 1998' ]�/✓•O — 7 <br /> x Tanks = <br /> F (multiply N by tee for <br /> A each year applicable) xxxx xxxx xxxx I xxxx (xxxx 1 7b 0 G I/76 ?d 74 5 0 <br /> G I I/7o o I/ 176 7a 17v 5 ro <br /> I TANK PENALTY FEES ASSESSED 1 XX7(X I xXXX xxxx xxxx XxxX D <br /> L 5 .Q jj <br /> I7STATERCHARGE FOR NEW FACILITIES ONLY=S18.50 -tr 3-L <br /> TY x 58.001993 ehrough 1997 (556) 1998 <br /> GE FOR 1, 1 xx=D=xxxXxxxxxxXxxxxxXxX xxxXxxxxxxxxxXxXxxXxxxx 5 U <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. d(s) <br /> OI CLOSURE FEE = 578.00/hour (3 hours minimmVTANK) 1 X TANK(S)_ x 5234.00 = 15 <br /> 5 <br /> TANK [.D. N(s7 <br /> Ul TEMPORARY CLOSURE (Plan Review & Inspections) <br /> :[TEMPORARY <br /> S <br /> TEMPORARY CLOSURE IEE = 578.00/hour (3 hours mininAm/FACILITY) 5234.00 mini <br /> P INSTALLATION PLAN CHECK (P(an Review & Construction Inspections)I TANK I.D. S(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction InspectiorLS) I TANK I.O. it(s) <br /> EIS <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) R TANK(5) X 5234.00 = <br /> A = 5134.00 minimum I S <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br /> R I g <br /> PIPING REPAIR FEE = 578.00/hour (3 hours miniman/FACILITY) = 5234.00 minimum <br /> N TRANSFERFEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr 1 I 5 <br /> I � <br /> S S <br /> C CONSULTATION FEE = 578.00/hr 1 SAMPLING INSPECTION FEE = 578.00/hr 1 <br /> TOTAL DUE 5 <br /> FOR OFFICE USE ONLY <br /> SWEEPS >t COMPUTER N LOC CODE 0[5T CODE AMOUNT ftECEIVEO CHECK ;O/CASH RECEIVED BY DATE RECEIV _ <br /> EH 23 032 (REVISED 1.12-98) . • <br />