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� • �► SAN J0AQUINTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVSION <br /> &GROUND STORAGE TANK PROGRAM - FEE WORKSHEE <br /> S FACILITY SITE N4ME T c �y L y. + FACILITY CONTACT NAME, r .�I <br /> I l CO IJIY O 1 1" 4-V p I CJ--t•" "1 `CAS <br /> T <br /> E FACILITY ADDRESS SITE PH&E It with AREA CODE <br /> & <br /> 4-701 ""LS c Avt'1uP. (10q) Is-a- 0L <br /> CITY ` STATE ZIP CODE # of TANKS <br /> +,3 <br /> e <br /> A S ,3C f v� cf� at SITE a. <br /> P <br /> P APPLICANT/BILL NG NAME APPLICANT CONTACT NAME <br /> 6Lct4 PETKo LE%A-m bhvID PN EH <br /> C MAILING ADDRESS , APPLICANT PHONE # WITH AREA CODE <br /> A P �ioK 36 � z3o C4'�J 9 �z -8656 <br /> N <br /> T CITY Mit STATE ZIP CODE TYPE of APPLICATION - -�^ <br /> C (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A %xXx xxxx I xx%% XXX% %Xx% S Xxxxx%%% <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %XXX %%XX %X%X %XXX X%%% 5 %%X%XX%X <br /> 1 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 Ali <br /> F (multiply # by fee for <br /> A each year applicable) xxxX Xx%x XXXX XXXX xx%X I 3 <br /> C <br /> 1 TANK PENALTY FEES ASSESSED XXXX XxxX %xxx xxxx XXxx S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 IS <br /> T <br /> Y # Tanks_ x $8.00 1988 through 1990 ($56) F <br /> 1991 through 1996 (S56) 1997 <br /> SURCHARGE FOR 1997 xxxxxxxxxxxx%xxxxxxXxxxxx%x XXx%XX%%XXXxx%XXXXXxxxx 2 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.O. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X 5234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum 3 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = 578.00/hour (8 hours minimus/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK i.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234-00 = 3 <br /> A <br /> 1 TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S <br /> M <br /> TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.001hr I y <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = $78.00/hr 3 <br /> TOTAL DUE 3 <br /> FOR OFFICE USE ONLY <br /> ::_:::.:: .:.:::::.:.:..:.:i::::...... . ............... .. <br /> _.!:�_!r .: . ..:::. .__.._ �_:�.::.:::::::,_.:: ::::_:!:air!!':u!r'r:ei.i",:i'.r:an:!x!ua!!!�tir!::!ir.e!_.:,!:: . ..... <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> :.I.... .... .._.................. ...... ......... _,.. .. .,._._.....,..,... <br /> EH 23 032 (REVISED 5-27-97) <br />