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SAN JOA I TY PUBLIC HEALTH SERVICES - ENVIRONMENT LTH OIVSION <br />RGROUND STORAGE TANK PROGRAM - FEE WOR <br />S <br />I <br />FACILITY SITE AME fj <br />FACILITY CONTACT NAME <br />11988 ' <br />1989 � 1490 <br />T <br />to January 1, 1991) = S100.00 <br />CLOSURE FEE = S78.00/hour (3 hours miniman/TANK) <br />E <br />FACT TY ADDRESS <br />SITE PHONE 4 with AREA CODE <br />UI <br />A <br />(Paan Review & Inspections) I <br />xxxx <br />xxxx xxxx <br />A <br />CITY <br />STATE ZIP CODE <br />N of TANKS <br />at SITE <br />TEMPORARY CLOSURE <br />FEE = S78.00/hour (3 hours minimurt/FACILITY) ( <br />S234.00 minimum S <br />P <br />(if Applicable) <br />P <br />APPLICANT/BILLIN-9 NAME ® APPLICANT CONTACT NAME <br />L, <br />S XXXXXXXX <br />I <br />Cl <br />A <br />MAILING ADORE SS ` APPLICANT PHONE WITH AREA CODE <br />7 `C —� <br />0 <br />T <br />CITY <br />�9 <br />STATE ZIP CODE TYPE of AEilati <br />I, <br />(Prior to January 1,1991) <br />S�L, Ll Z2 d2a� I <br />C 4(Closure, etc.) <br />TOTAL <br />C! PERMANENT CLOSURE <br />(Removal or Authorized Ctosure-in-Place) ( <br />' 1986 11987 <br />11988 ' <br />1989 � 1490 <br />ANNUAL FACILITY FEE (Prior <br />I <br />to January 1, 1991) = S100.00 <br />CLOSURE FEE = S78.00/hour (3 hours miniman/TANK) <br />4 TANK(s) X 5234,00 = S <br />S— <br />UI <br />A <br />(Paan Review & Inspections) I <br />xxxx <br />xxxx xxxx <br />XXXX XXXx <br />S xxxxxxxx <br />C <br />Ei <br />TEMPORARY CLOSURE <br />FEE = S78.00/hour (3 hours minimurt/FACILITY) ( <br />S234.00 minimum S <br />Ti FACILITY PENALTY FEES ASSESSED <br />(if Applicable) <br />XXXX I <br />XXXX xxxx <br />XXXX XXXX <br />S XXXXXXXX <br />I' <br />VI TANK FEE = S50.00/TANK <br />(Prior to January 1,1991) <br />5170/TANK <br />(After January <br />1, 1991) <br />E; <br />4 Tanks = <br />1988 1989 1 1990 1991 1992 11993 <br />i1994 i <br />1995 ¢ 1996 <br />1997 ' 1998 <br />F1 (multiply 4 by fee for <br />AI each year appiicable) <br />I XXXX ` XXXX P XXXX ! XXXX XXXX I <br />` i <br />! <br />S I , <br />C1 <br />II TANK PENALTY FEES ASSESSED <br />i XXXX ` XXXX 1 XXXX I XXXX XXXX <br />I ' <br />f <br />I <br />S <br />L. <br />II STATE SURCHARGE FOR NEW FACILITIES <br />ONLY=518.50 <br />S <br />T, <br />Y;l Tanks,3 58.00 <br />1988 through 1993 (S56) <br />1993 through <br />1997 (E -El <br />998 <br />SURCHARGE FOR 1998 <br />XXxxxxxxxXXXXXXXXXXXXXxxxxx <br />XXXXXXXXXXXXXXXXXXXxxxx <br />5 <br />C! PERMANENT CLOSURE <br />(Removal or Authorized Ctosure-in-Place) ( <br />TANK I.D. t(s) <br />l; <br />Of <br />CLOSURE FEE = S78.00/hour (3 hours miniman/TANK) <br />4 TANK(s) X 5234,00 = S <br />S— <br />UI <br />TEMPORARY CLOSURE <br />(Paan Review & Inspections) I <br />TANK I.O. l(s) <br />R` <br />Ei <br />TEMPORARY CLOSURE <br />FEE = S78.00/hour (3 hours minimurt/FACILITY) ( <br />S234.00 minimum S <br />P! INSTALLATION ?LAN CHECK (Plan Review & Construction Inspections)! TANK I.D. ;*(s) <br />L, <br />AIc� S <br />NI PLAN CHECK FEE = 578.00/hour (8 hours minimae/FACILITY) = 5624.00 minimum � <br />RI REPAIR FEE (Workpian Review & Construction Inspections) TANK I.O. N(s) <br />E <br />P! TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = S <br />A' <br />I1 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br />R, <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br />MI TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I I S <br />I' I f I <br />Si <br />C; CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE = S78.00/hr I 1 S <br />TOTAL DUE S <br />FOR OFFICE USE ONLY <br />EH 23 032 (REVISED 1-12-98) <br />