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S-26-1998 1 :48PM FROM P. a <br /> SAN JQ#AUIN COUNTY PUBLIC HEALTH SERVICES - ENVIROMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I - C. - CL 1 <br /> T <br /> E FACILITY ADDRESS SITE PHONE with AREA 60CE <br /> K �L� - u s7 <br /> CITY STATE ZIP CODE Rot TANKS <br /> A I� at SITE <br /> P <br /> P APPLICANT/MILLING HAIR; APPLICANT CONTACT NAME <br /> --r W r-i-"'5 <br /> t <br /> C MAILING ADDRESS APPLICANT PHONE R WITH AREA CODE <br /> 5'7►. <br /> T CITY STATE ZIP CODE TYPE Of APPLICATION =zCl;Tz—Cnj <br /> 11 SOS CIS (Closure, Instittacfon, etc.� <br /> TOTAL <br /> , <br /> ANNUAL FACILITY FEE (Prior to January 1, 1997) = stOp.Op 1986 1987 19W 19M 1990� <br /> A )0= =tx xxxx xxxx =cx S xxx7 o= <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If ApptiCsbte) = XXXX XXXX XXXX XxxX )000[ i xxxxx= <br /> I <br /> V TANK FEE a S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January t, 1991) <br /> E <br /> 2 Tanks a 1987 1988 4 1989 1990 1991 1992 1993 1994 1995 19% 1997 <br /> F (as+tt4pty # ar fee for <br /> A each year appticabie) XXXX XXXX xXXx XXxX XXXX ' S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX xxxx X;= xxxx 5 <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY a $18.50 =5 <br /> T <br /> Y x Tanks x 58.00 1988 through 1990 ($56) 1991 through 1996 (S56) 1497 <br /> SURCHARGE FOR 1997 XXX S <br /> C PERWEvT CLOSURE (R t or Authorized Ct -in-Ptwe) TANK I.D. R(s> <br /> L <br /> *I CLOSURE FEE : 578-00 0 hours minimum/TANK) S TANK(s) X 5234.00 c S <br /> S <br /> U TEMPORARY CLOSURE (Ptah Review 6 Inspections) TANK I.D. R(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.001hour (3 hours miniwuwFACILITY) 5234.00 minims S <br /> P INSTALLATION PLAN CHECK (Ptah Review & Construction Inspections) TANK I.D. s(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimusfFACiLITY) ■ S624.00 minimum S <br /> R REPAIR FEE (Workplan Review iC Construction inspections) TANK I.C. R(s) <br /> E <br /> P TANK LINING REPAIR FEE 9 5713.00/hour (3 hours mini=mVTANK) R TANK(s) X $234-00 : S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) a S23L.00 mina $ <br /> R <br /> PIPING REPAIR FEE : S78.00/hour C3 hours mini FACILITY) 523L.Op minimum i <br /> N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION a 578.00/hr S <br /> I.I " <br /> S <br /> C CONSULTATION FEE = 378.00/hr SAMPLING INSPECTION FEE = 578.00/hr s <br /> TOTAL DUE S LID j <br /> FOR OFFICE USE ONLY <br /> SWEEPS R ! COMPUTER 9 LOC CDOE DIST CODE T RECEIVED CHECK $/CASN RECEIVED BY 1 -DATE RECEIVED <br /> a <br /> a5 f <br /> S <br />