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+ SAN JOA(1UIN COUNTY PUBLIC HEALTH SERVICE* <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGRCUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME �TT� <br /> A �� �— C2v I CE �jTp�'ri c�l•l H IQ'FK+.l K I%W e.L, <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L 431 -5-T^j1QA l-:> CA_05 <br /> T CITY T STATE ZIP CODE # of TANKS <br /> Y 47_T0� l QFat SITE <br /> AP APPLICANT/BILLING NAME APPLICANT CONTACT NAME �1 r <br /> LOM <br /> L ,. <br /> .t r <br /> 1 MAILING ADDRESS APPLICANT PHONE # WIIA AgEA C4'.k7E',1� <br /> N CITY STATE ZIP CCOEQTYPE of APPL1CA7lONMadP�l_ <br /> TK�j '�� G9c3' CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I S <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) S <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> 1 - <br /> T # Tanks x 556.00 1486 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = S53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = __F4_1 <br /> '�'�,�(] <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S150.00 each TANK # TANK(S) X $150.00 = S <br /> P PLAN CHECK (Instatl. Plan Review 8 Construction Inspections) TANK 1.0. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 553.00 per hour (8 hours minimum per Facility) = S424.00 minimum S <br /> R REPAIR FEE (workplan review b construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) # TANK(s) X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE 553.00 per hour (3 hour minimun per facility = $159.00) S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S53.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 553.00/hr 1 SAMPLING INSPECTION FEE = 553.00/hr S <br /> // r/ TOTAL DUE S D <br /> OFFICE USE ONLT / V i17' <br /> ................................................................................................................................................................................................................................. <br /> we:rw weoe fr»�»..rue rMOe»»fors four»aee feo«fe®rwo�.»fee rw reo sees sere fe.rre fine rwe fw roe tier»»»re��...re•feeew fere fire»>...ra fiefs reef feser r«fire»re M..ferric fees ries»»freer>...�..,.�..fie aeerr.w r <br /> g s € s c ' <br /> i_ff rorc in 1` s c ��c'"ro ��cA ► L t� r �, <br /> a 5 <br /> m.......................... .......,................ ...,.........,...... ........................ .,.............................. ........... .................................... <br /> .. ........ ........................................... <br /> fro r.w ee rsr r�fc ere ref f...e r»fre»„»rr..e r.» fee f.r.rrsr.re fess re sea rsr re rues..r.w or r....rres......r»...; r»eFer _� <br /> EH 23 032 PREY 4J8141) it Paas 11 <br />