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SAN JOAOU OUNTY PUBLIC HEALTH SERVICES - ENVIRONNEMT EALTH DIVSION <br /> MDERGROUND STORAGE TANK PROGRAM - FEE WORX. •T <br /> Si FACI IT / iT �ME FACILIT C TACT NAM. Z6 <br /> T T <br /> EI FACILITY ADI SS I SITE PHO E x w A� CODE <br /> 1p i d - <br /> b' i <br /> CITY j STATE CODE j # of TANKS l <br /> C <br /> j i L, t s;r <br /> P' <br /> i <br /> P! APP L T/B ��I iAP ICANi CONTAC`C"E i <br /> C! MAIL G ADDRESS LMo!CANT PHONE - WITH AREA CODE Y <br /> A! 4;,V)— K-A aj'a ff /;�z- <br /> N' <br /> I TI C.TY , / IS E; ZIP CODE TYPE of APPLICATION <br /> ji (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1 1988 j 1989 1 1990 <br /> ANNUAL FACILITY EE (Prior to January 1, 1991) = 5100.00 <br /> Al xxxx j xxxx xxxx xxxx j xxxx 15 xxxxxxxx <br /> G <br /> T' FACILITY PENALTY EES ASSESSED (If Applicable) XXXX XXXX I XXXX j XXXX ! XXXX S XXXXXXXX <br /> � I <br /> V' TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January i, 1991) <br /> ! c <br /> �! = Tanks = j 1987 j 1988 1989 j 1990 i 1991 1992 1993 i 1994 1995 j 1996 i 1997 <br /> C F! (multipiv T by fee for p <br /> A; each year appiicabie) XXXX XXXX j XXXX I XXXX XXXx i S <br /> 9C. <br /> I' TANK PENALTY FEES ASSESSED XXXX j XXXX XXXX I XXXX xxxx j j j $ <br /> L <br /> 9 I! STATE SURCHARGE FOR NEW FACILITIES ONLY = 518.50 "S <br /> T: <br /> T 4 Tanks x S8.00 j 1988 through 1990 (556) 1991 througn 1996 (S56)1 1997 <br /> 3 B <br /> SURCHARGE FOR 1997 XXXXXXXXXxxxxxxxxxXXXXXXXXX XXXXXXXXXXXxxxxxxxxXXXx S <br /> i <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK i.D. 9(s) <br /> L' <br /> 01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) R TANK(s) X -52#00 <br /> S:-- v <br /> UI TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. :(s) <br /> R' <br /> E TEMPORARY CLOSURE F=E = 578.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br /> P; INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)i TANK I.D. T(s) <br /> L' <br /> Aj <br /> NI PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> RI REPAIR FEE (Workplan Review & Construction Inspections) i TANK I.D. :(S) <br /> PI TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) i # TANK(s) X 5234.00 = i S <br /> A' <br /> IJ TANK RE7ROF17 REPAIR FEE = 578.00/hour (3 hours min./FACILITY) _ $234-40 minimum cc) S <br /> R! <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE = $20.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr i S <br /> I, <br /> SL. I I <br /> Ci CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr j S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY �o <br /> ...-=---...---_--- _ _ <br /> SWEEPS # I COMPUTER # j LOC CODE I DIST CODE j AMOUNT RECEIVED CHECK :/CASH I RECEIVED 3Y j DATE RECEIVED <br /> - <br /> ._ <br /> EH 23 032 (REVISED 5-27-97) <br />