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S <br />I <br />T <br />E <br />& <br />A <br />P <br />P <br />L <br />I <br />C <br />A <br />N <br />T <br />A <br />C <br />T <br />a <br />Y <br />E <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />SAN JQA0UIA1WUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAMWALTH DIVISION <br />RGROUND STORAGE TANK PR - FEE WORKSHNW <br />FACILITY SITE NAME <br />JooD C <br />FACILITY CONTACT NAME <br />5iu ma se - <br />FACILITY ADDRESS <br />236P 0 W L4NE <br />SITE PHONE # with AREA CODE <br />Z001- 333- k 3 00 <br />CITY ' <br />S ATE <br />ZIP CODE <br />mi <br /># of TANKS %® �'t <br />at SITE i — 5 /06 <br />$ <br />XXXX XXXX XXXX <br />XXXX <br />XXXX <br />NAME c <br />V <br />APPLICANT CONTACT bN�AME <br />l/.� <br />I vd J <br />Jru (n% <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />5l� — (t 2-- qS-2-8 <br />CITY <br />S ATE <br />ZIP CODE <br />9 <br />TYP f APPLICATION <br />osur Installation, etc.) <br />TOTAL <br />ANNUAL FACILITY FEE (Prior <br />to January 1, 1991) = $100.00 <br />TANK I.D. #(s) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />$ <br />XXXX XXXX XXXX <br />XXXX <br />XXXX <br />$ XXXXXXXXXXXXX <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />PIPING REPAIR FEE _ $78.00/hour (3 hours minim/FACILITY) = <br />$234.00 minim <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ XXXXXXXXXXXXX <br />TANK FEE _ $50.00/TANK <br />(Prior <br />to January 1,1991) <br />$170/TANK <br />(After <br />January 1, 1991) <br />$ <br /># Tanks = <br />(multiply # by fee for <br />each year applicable) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ <br />STATE SURCHARGE = $56.00 <br />each TANK <br />(Due every 5 <br />years) <br />See California H & S Code, <br />Section 25287 <br /># Tanks x $56.00 <br />(Enter amount and year) <br />1988 through <br />1990 <br />1991 through 1996 <br />C PERMANENT CLOSURE (Removal or Authorized CLosure-in-PLace) TANK I.D. #(s) <br />L <br />0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br />S <br />U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br />R <br />E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minim $ <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 minim $ <br />R <br />E <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />P <br />A <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) <br /># <br />TANK(s) X $234.00 = <br />$ <br />I <br />R <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = <br />$234.00 minimum <br />$ <br />PIPING REPAIR FEE _ $78.00/hour (3 hours minim/FACILITY) = <br />$234.00 minim <br />$ <br />M <br />I <br />TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION <br />= $78.00/hr <br />$ <br />S <br />C <br />CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE <br />= $78.00/hr <br />$ <br />FOR OFFICE USE ONLY <br />TOTAL DUE <br />$ <br />