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SAN JGAOUINI&TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL <br /> �LTH DIVSION <br /> RGROUND STORAGE TANK PROGRAM - FEE WORKSX <br /> S FACILITY SITE NAME 1 FACILITY CONTACT NAME <br /> I YI�jF ^�' S '1 c� 1 Ll•.o f Y!•o J o 5'T <br /> T SITE PHONE # with AREA CODE <br /> 'E FACILITY ADDRESS <br /> y � WRS�- �o I..:.� P.,� � �z zs' <br /> 1 <br /> & STATE ZIP CODE # of TANKS <br /> A CITY �-33 at SITE ' <br /> P n 0" D <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L 2v 0. SS <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C nMAILING ADDRESS <br /> A do TQ., o �a S,Ae <br /> T CITY STATE ZIP CODE TYPE of APPLICATION U050 -A <br /> (� n �' (Closure, Installation, etc.) <br /> J �+' <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 8100.00 XXxx XXXX XXXX XXXX XXXX $ XXXXXXXX <br /> A <br /> CXXXX XXXx Xxxx XXXX XXXX $ Xxxxxxxx <br /> T FACILITY PENALTY FEES ASSESSED (If AppLicable) <br /> I $170/TANK (After January 1, 1991) <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) <br /> E <br /> # Tanks = _ 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 <br /> F (multiply # by fee for g <br /> A each year applicable) XXXX XXXX XXXx XXXX XXXX <br /> C $ <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXx XXXX XXXX <br /> L S <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 <br /> T <br /> Y # Tanks_ x $8.00 1988 through 1993 (856) 1993 through 1997 (856) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXxxxxxxxXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L # TANK(s) I X $234.00 = $ <br /> O CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) ,C77 <br /> STANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R $ <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A $ <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimus <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours mini nssn/TANK) # TANK(s) K $234.00 = $ <br /> A $ <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum <br /> R $ <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> S $ <br /> Cl CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE _ $78.00/hr <br /> TOTAL DUE $ Ob <br /> FOR OFFICE USE ONLY -- ! <br /> ..........i.i.i.i....._..........a.n......._. ._.....:...... ....... ': <br /> .._._.............._......... ..__r:_c..c:...._:..:.r__ <br /> ::-::::::.....:..::::• :... !=!_!!n!!!n!!u.: .!::::!'!s.:! :!snn :n!5!!!!n!!!5! n!:!!::.y_!:!!!!!!:r!=_ :!!!_�.:._.....n.:.__,::::_._—..... RECEIVED <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE <br /> EH 23 032 (REVISED 1-12-98) <br />