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{ <br />• SAN JOACIII NTY PUBLIC HEALTH SERVICES - ENVIRONMENTA LTH DIVSION <br />ERGROUND STORAGE TANK PR - FEE WORKSH r <br />SI <br />IC41 <br />FAC .LITY <br />SITE NAME <br />° <br />L; <br />FACILITY CO N <br />T <br />j 1989 <br />11)74, <br />AI <br />C' <br />EI <br />FACILITY <br />ADDRESS <br />XXXX <br />i XXXX <br />SITE PHONE # with AREA COD I <br />XXXX <br />S XXXXXXXX <br />R� <br />T'!, <br />I <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX <br />CITY <br />I XXXX <br />! XXXX <br />TAT= <br />ZIP CODE of TANKS I <br />AI <br />TANK FEE = 550.00/TANK <br />(Prior to January 1,1991) 1 <br />5170/TANK <br />(After <br />at SITE I <br />P <br />€ <br />F! <br />9 Tanks = <br />(multipiy # by fee for <br />1987 1988 1 1989 <br />11990 i ?qq? <br />P! <br />APPLIC <br />/ I ING E <br />i 1996 <br />� APP I" T C NTACT,N E <br />LI <br />XXXX XXXX <br />I <br />I <br />S <br />s Al each year appiicable) ! XXXX XXXX XXXX <br />g <br />C! <br />N ! <br />MAIL'NG ADDRESSAPPLI <br />r <br />C>6B <br />I XXXX XXXX 1 XXXX I XXXX iXXXX <br />NT PHON # I H gREA 0 <br />C; <br />I <br />g <br />y <br />Ij <br />T' <br />STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 <br />TOTAL DUE <br />STATE, <br />IP CODE TYPE of APPLICATION <br />y5 <br />__._.................._...... ._............—:-.-::._ <br />SWEEPS COMPUTER # I LOC CODE DIST CODE I AMOUNT RECEIVED <br />71 <br /># Tanks x 58.00 <br />(Closure, Installation, etc.) <br />1991 through <br />1996 <br />(S56)1 1997 <br />TOTAL <br />11986 <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections), <br />ANNUAL FACILITY FEE (Prior <br />to January 1, 1991) = 8100.00 <br />L; <br />1987 <br />1988 <br />j 1989 <br />1990 <br />AI <br />C' <br />NI <br />PLAN CHECK FE_ = $78.00/hour (8 hours minimum/FACILITY) <br />XXXX <br />XXXX <br />i XXXX <br />i XXXX <br />XXXX <br />S XXXXXXXX <br />R� <br />T'!, <br />I <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX <br />XXXX <br />I XXXX <br />! XXXX <br />S XXXXXXXX <br />r <br />V' <br />E' <br />TANK FEE = 550.00/TANK <br />(Prior to January 1,1991) 1 <br />5170/TANK <br />(After <br />January 1, 1991) <br />0 <br />€ <br />F! <br />9 Tanks = <br />(multipiy # by fee for <br />1987 1988 1 1989 <br />11990 i ?qq? <br />1992 1993 <br />1 1994 <br />I <br />i 1995 <br />I <br />i 1996 <br />1997 <br />S <br />XXXX XXXX <br />i <br />I <br />S <br />s Al each year appiicable) ! XXXX XXXX XXXX <br />g <br />Ii <br />L <br />TANK PENALTY FEES ASSESSED <br />I XXXX XXXX 1 XXXX I XXXX iXXXX <br />C; <br />I <br />g <br />y <br />Ij <br />T' <br />STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 <br />TOTAL DUE <br />S Q <br />FOR OFFICE USE ONLY <br />y5 <br />__._.................._...... ._............—:-.-::._ <br />SWEEPS COMPUTER # I LOC CODE DIST CODE I AMOUNT RECEIVED <br />71 <br /># Tanks x 58.00 <br />i 1988 through 1990 (S56) <br />1991 through <br />1996 <br />(S56)1 1997 <br />SURCHARGE FOR 1997 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XXXXXXXXXXXXXXXXXXXXXXX <br />S <br />S <br />S <br />P± <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections), <br />TANK I.D. #(s) <br />L; <br />Aj <br />NI <br />PLAN CHECK FE_ = $78.00/hour (8 hours minimum/FACILITY) <br />= 5624.00 minimum <br />$ <br />R� <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />PI <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />S <br />A <br />II <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= $234.00 minimum <br />$ <br />R` <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />= 5234.00 minimum <br />S <br />N) <br />TRANSFER FEE = 520.00 I ( UNAUTHORIZED RELEASEE EVALUATION = $78.00/hrI i <br />S <br />II <br />S <br />C; <br />CONSULTATION FEE = $78.00/hrSAMPLING INSPECTION FEE <br />= 578.00/hr <br />S <br />TOTAL DUE <br />S Q <br />FOR OFFICE USE ONLY <br />__._.................._...... ._............—:-.-::._ <br />SWEEPS COMPUTER # I LOC CODE DIST CODE I AMOUNT RECEIVED <br />.-----....----'__:::..� -- ...-.__.-:.—:::--::: <br />I CHECK #/CASH RECEIVED BY ( DATE RECEIVED <br />_._._ <br />.._.......-- - ( <br />S <br />EH 23 032 (REVISED 5-27-97) <br />