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a-c---�- A SAN JOAOUINNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL " LTH D MION <br /> GROUND STORAGE TANK PROGRAM - FEE WORKSH <br /> S FACILITY ::J�Z O.CX(J FACILITY CONTACT NAM <br /> I <br /> T <br /> E FACILITY ADDRESS SITE PHMOF; with AREA CODE <br /> g r7lt� 117 <br /> © — AFfrpJ <br /> CITY / STATE ZIP CODE 9 of TANKS <br /> A /P 3 at SIT€ <br /> P [� <br /> P� APPLICANT/BILLING NAM APPLiCA T CONTACT <br /> L <br /> i <br /> C MAILING ADDRESS APPLICANT PH NE T WITH AREA CODE <br /> N S3 - <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> 9 zor- I (Closure, installation L etc.) <br /> TOTAL <br /> 1986 1987 f 1988 � 1489 � 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ S100.00 <br /> A xxxx ! XXXX xxxx XXXX xxxx S xxxxxxxx <br /> C. <br /> Tj FACILITY PENALTY FEES ASSESSED (I` Applicable) xxxx { xxxx j XXXX i XXXX XXXX 5 xXXXXXXX <br /> I; <br /> VI TANK FEE 550.00/7ANK (Prior Co January 1,1991) 5170/TANK (After January 1, 1991) <br /> E'. - <br /> Tanks = 1987 1988 1989 j 1990 1991 k 1992 ! 1993 1994 1 1995 11996 11997 <br /> F (multiply T by fee for <br /> Cl earl year applicable) xxxx xxxx xxxx xxxx IxxxX 4 I a 5 <br /> II TANK PENALTY FEES ASSESSED xxxx I XXXx XXXX XXXX �XxxX S <br /> L <br /> I! STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 I5 <br /> T <br /> Y! 9 Tanks x 58.00 1988 through 1990 (S56) 1991 througn 1996 (S56)l 1997 1 <br /> SURC4ARGE FOR 1997 XxxxxxxxxxxxXXXXXXXXXXXxXXX xxXxxxxxxxxxXxxXXXXXXXX it 5 <br /> C; PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. T(s) <br /> L <br /> 01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) M TANK(s) X 5234.00 = S { <br /> S: <br /> UI TEMPORARY CLOSURE (PLan Review & Inspections) I TANK 1.0. l(s) <br /> R <br /> EI TEMPORARY CLOSURE FE=- = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum 5 <br /> P! iNSTALLATION PLAN CHECK (Plan Review & Construction Inspeetions)l TANK I.D. A(s) <br /> L; <br /> A <br /> N{ PLAN CHECK FL_ = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Constructien Inspections) TANK I.O. =(s) <br /> P! TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) 1 TANK(s) X 5234.00 = $ <br /> - <br /> I1 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 5234.00 minimum 5 -P-341 ry00 <br /> R! <br /> I PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> K TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr i S <br /> Sl <br /> Cl CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = $78.00/hr I S <br /> TOTAL DUE S23 <br /> b <br /> FOR OFFICE USE ONLY <br /> -Wit..... : w—s::�—:—: s:cr ==—-- —_.::__-__: __:::: :- _:__:._.__:_____.....:..: <br /> .:..:..._..........._..... �- <br /> - <br /> SWEEPS COMPUTER LOC CODE I DIST CODE AMOUNT RECEIVED CHECK �/CASH RECEIVED 3Y I DATE RECEIVED _ <br /> S <br /> EH 23 032 (REVISED 5-27-97) <br />