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SAN JDAQU[N COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DlYSIOM <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE UORKSHEET <br /> FACILITY CONTACT NAME <br /> FACILITY SITE NAME 11 <br /> 'pcfal <br /> 0 1-L <br /> T0 SITE PHONE # with AREA COD <br /> E FACILITY ADDRESS pg0q- x25 -v73t? <br /> 8 31x44 `�'� � 33 STATE ZIP CODE # of TANKS /+ <br /> CITY 'Of-ga� at SITE VA-3� RELEIVF <br /> A LHA � <br /> / `' <br /> P APPLICANT CONTACT NAME ��AN 1 � 1993 <br /> P APPLICANT/BILLING ME <br /> L ,5At4E A5FtBtatl� <br /> 1 APPLICANT PHONE # UITH AREA MSL.IC 4��.ALTFI�ER111G .` <br /> C MAILING ADDRESS ENVIRONMENTAL HEALTH DIV SII <br /> A <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) RECO�A L— <br /> T <br /> T CITY <br /> TOTAL <br /> 1986 1987 1988 1989 , 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 $ <br /> A $ <br /> C )(XXX xxxx <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I 5174/TANK (After January 1, 1991) <br /> V TANK FEE = $50.04/TANK (Prior to January 1,1991) <br /> E 9 Tnks 1986 1987 1988 1989 1990 1991 1992 K 1493 1994 1995 1996 <br /> a <br /> F (multiply # by fee for $ i�V•� <br /> A each year applicable) $ <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx <br /> L <br /> 1 STATE SURCHARGE : $56.04 each TANK (Due every 5 year See California N 8 S Cate, Section 25287 <br /> 1991 through 1996 <br /> T <br /> through 1990 <br /> 1986 <br /> Y N Tnnks x $56.00 S <br /> (Enter amount and year) <br /> TANK I.D. <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) $ w <br /> L # TANK(s)rL X $234.00 <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /> STANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review 8 inspections) $ <br /> R # TANK(s) X <br /> TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimus/TANK} <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A - $624,00 minimum <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) <br /> #(s)D, <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK 1. $ <br /> E # TANK(s) <br /> X $234.40 = <br /> P TANK LINING REPAIR FEE = $78.40/hour (3 hours minimum/TANK) $ <br /> A = $234.00 minimum <br /> 1 TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) $ <br /> R = $234.00 minimum <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) <br /> H TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION <br /> $78.04/hr $ <br /> I _ $ <br /> SSAMPLING INSPECTION FEE = $78.00/hr <br /> C CONSULTATION FEE = $78.00/hr TOTAL DUE <br /> :•^na::•s•{z?i?i!E!i!iii!iii!iiE!!i!i!i!£nii!II!i£!Iii?£!I!ili?i?i££??!Viii;{I�111luili£tl�i�ilillll£i£ili!li!N <br /> R:e::F:£:O3£!RfSOsll£FF!£!I <br /> lnilifG!£!!iE£i1£iU IiSu{lEl.l.f.rIONLY<. <br /> i!£i i!!!1£{�'IiIIII:iIy rliHh£ £f Ser :1 rI lul i <br /> G!?i!i!E!!!^°i RECEIVED 8Y t DA:T...E... <br /> RECEIVED <br /> =...0 <br /> r <br /> 5UEEP5 # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CA SII <br /> fi $ •rni II£i£!i!ilii IliiIli!!!s!i{i:il?!!£EIII!£i!i?i!£i£!FiiF!Ii IIIPII 111[dcr si!i££{.{{liiTin!I!i rin's!!!11Rei{i.3F11r�I!!!?irE?£:::s 11 t113'ii.frs'Er'Ei��I� <br /> • rr•: a e. :e {iil!I Iilf Iin£In!i!!Iliii'£E!!!,#11p11 llilll!li;q 13i£f!in{ilii I n111Lin£�S{e{lIs 3{.Iil:Hull�£;•illr;:;;!!n£Kenn i <br /> EH 23 032 (REVISED 11 1 92) 1 <br />