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/FACILITY <br /> SAN JOACKJIN COUNTY PUBLIC HEALTH SERVICES - FNVIRONMNtAL HEALTH DiVSION <br /> UNDERGROUND STORJIGE TANK PROGRAM - FEE WORKSHEET <br /> W . SiTE NAME FACILITY CONTACT NAME <br /> tT <br /> E FADDRESS <br /> �J SITE PHONE N with AREA C ' <br /> ao4- 8�5 -a8 <br /> STATE ZIP CODE N of TANKS <br /> CiTT /�j� et SITE OSE RECEIVED <br /> P APPLICANT/BILLING ME APPLICANT CONTACT NAME j A N 1 1 1993 <br /> L .SAME /�5 ABa�E _ c_nr <br /> 1 -- <br /> C HAILING ADDRESS APPLICANT PHONE N WITH AREA P"L.IC IiF.AtTIi SERVIC <br /> A ENVIRONMENTAL HEALTH 01]� <br /> M — <br /> T CITY STATE ZiP CODE TYPE of APPLICATION �7 <br /> (Closure, installation, etc.) I Mo VA L <br /> TOTAL <br /> 1986 1987 1988 1989 . 1990 <br /> ANWAL FACILITY FEE (Prior to January 1, 1991) 5100.00 s <br /> A <br /> T FACILITY PENALTY FEES ASSESSED (1f Appticable) XXXX XXXX <br /> I <br /> V TANK FEE = 550.00/7ANK (Prior to January 1,1991) 1170/TANK (After January 1, 1991) <br /> E <br /> t1 Tanks _ 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 199 <br /> F (multiply fee for <br /> A each year applicable) 5 1-70. <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX <br /> L <br /> I STATE SURCHARGE - 156.00 each TANK (Due every 5 years) See California H 6 S Code, Section 25287 <br /> T — --- <br /> r N Ten%• w RSi.oO 1986 throuph 1990 1991 through 1996 <br /> (Enter ;mount and year) ! <br /> C PERMANENT CLOSURE (Removal or Authorized Cloture-in-Plece) TANK I.D. N(s) qq- Pc, <br /> L N TANK(a) r <br /> D CLOSURE FEE , 978.00/hour (3 hours minimum/TANK) � X 5234.00 � 5 � W <br /> 5 <br /> U TEMPORARY CLOSURE (Plan Review R inspectlons) TANK I.D. k(s) <br /> R = 5 <br /> E TEMPORARY CLOSURE FEE r 578.00/hour (3 hours minimlm/TANK) N TANK(s) X 5234.00 <br /> P INSTALLATION PLAN CHECK (Plon Review R Construction Inspections) TANK I.D. III(S) — <br /> L <br /> A !624.00 minimum 5 <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minllnum/FACILITY) - <br /> R REPAIR FEE (Workplan Review 6 Construction Inspections) TANK I.D. N(a) <br /> E <br /> P TANK LINING REPAIR FEE - !78.00/hour (3 hours minirmrn/TANK) N TANK(s) X 5234.00 = 5 <br /> A 52.34.00 minimum 5 <br /> 1 TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br /> R um = $234.00 minimum 5 <br /> ' PIPING REPAIR FEE Q 578.00/hour (3 hours minim /iACiLiTY) <br /> III TRANSFER FEE 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 5 <br /> I <br /> S. <br /> C CONSULiATION FEE - 578.00/hr SAMPLING INSPECTION FEE = !78.00/hr 5•� <br /> TOTAL DUE D W <br /> FOR OFFICE USE ONLY mm <br /> 129-W <br /> ri n 1 I nilnn n.. IIIIIIIRG, i�[?uek'=xn!#Tnmm lmrin�L,tlYLmti;i�l!JISN n43mC'' FT��Ii,"i"_n'?i��t'r,?SC.Mn-.'','� !-If�.Ms�,rrtllulII"11': :- =�u=FI[ !I' luc.! <br /> qqp �mm :: ,r I '� {�°"��i�l:'In', ,� �Ira `.t•:z..I T11 ! .,...r.:r.!r?v'w," ..: ° .___._. .. <br /> 129— 9M=�IIP ..F .IIM,I aIi01'n!L .Ir:.li T. :J _ <br /> SWEEPS i! COMPUTER 11 LOC CODE DT S1 CODE AMOUNT RECEIVED CIiECK N/CASH RECEIVED BY DATE RECEIVED <br /> ra nm i mpjn>I 1I tt n moon Ir. 5 nun=. mm�m unl:g. n r u!.nl li nlmnnm mmmn <br /> 1lIp pn�e�nn�!!ppppm�(n1p�[�� pnmm��nr�, p p p�4:1 nor.1!11?I nl III! <br /> �h r=[x� r?gym i?itt?_.Gi n4!int S Ilf!111M.l!lFi,mm"m .f!m1:n ��minn!II?II!IfG!m!ifiglSnni.itl?f??!!?1^.tnnlP9m!!:.ti!ittC?F;nr?�nt},�"-rrirnlrnn,._I <br /> ..I_�Iln�!3'7f".!Ifl!I.!.r I'll IF IffB'F.I?:4ihd'f7fmlm!1!I!I?i! I liil'rm!!I!ifli:rn r?ll.n �m�H{I I" 4 =I .111!. n11�P4RO1 R IN .�I n .� Y14rlli'' <br /> EN 23 032 (REVISED 11-1-92) / hI !V K�/ nge 11 <br />