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SAN JOAOUINTY PUBLIC HEALTH SERVICES - ENVIR TAL TH D MION <br /> *ERGROUND STORAGE TANK PROGRAM - FEE WORKSH, <br /> SI r-AGILITY SITE NA6,a( FACILITY INTACT NAME. <br /> I <br /> T <br /> EI FACILITY ADDRESS _ I SITE PHONE # with AREA CODE <br /> AI CITY ? TE Z P CODE j # of TANKS <br /> J at SIT-c <br /> P <br /> PI, APPLICANT/ LL G E ! APPLICA ONTACT NAME <br /> L! <br /> C MAILI G ADORE APPLICANT PHONE W WITH AREA CODE <br /> Al ® / zop 13 <br /> - <br /> T� C:TY E; I TYPE of APPLICATION k <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> ` 1986 1987 i 1988 1 1989 1990 <br /> ANNUAL FACILITY F E (Prior to January i, 1991) _ $100.00 <br /> Al i XXXX XXXX i XXXX XXXX I XXXX $ XXXXXXXX <br /> C <br /> 4 <br /> T; FACILI?Y <br /> PENALTY FEES ASSESSED (If Applicable) 1 XXXX j XXXX j XXXX j XXXX XXXX S XXXXXXXX <br /> I' <br /> V; TANK F-= _ $50.00/TANK (Prior to January 1,199-') $170/TANK (After January 1, 1991) <br /> E' <br /> Tanks = 1987 1988 1 1989 1990 1991 i 1992 1993 1994 1995 i 1996 1997 1 <br /> F! (multiply # by fee for 1 <br /> Ai each year apoiicable) 1 XXXX XXXX ; XXXX XXXX (XXXX S <br /> C, <br /> II TANK PENALTY FEES ASSESSED I XXXX , XXXX I XXXX I XXXX -'XXXX $ <br /> ; <br /> L <br /> Ii STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 �$ <br /> T <br /> Yl Tanks x $8.00 1988 through 1990 (S56) 1991 through 1996 (S56)� 1997 <br /> j SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> i <br /> Ci PERMANENT CLOSURE (Removal or Authorized Closure-in-Piace) i TANK :.D. #(s) j <br /> L <br /> 01 CLOSURE F=_= = 578.00/hour (3 hours minimum/TANK) i R TANK(s) X 5234.00 = $ <br /> Si <br /> UITEMPORARY CLOSURE (Plan Review & Inspections) j TANK I.D. :(s) <br /> R. <br /> El TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) I $234.00 minimum S <br /> ; <br /> Pi INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)j TANK I.D. 9(s) y <br /> L. <br /> A! a <br /> N1 PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ <br /> i <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. (s) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) 0 TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr i $ <br /> I <br /> S I I 9 <br /> C, CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FE= _ $78.00/hr + S <br /> ` I <br /> TOTAL DUE $ <br /> 073ZI 6), <br /> FOR OFFICE USE ONLY <br /> ..........=::: = iss = - <br /> S = == <br /> ............. .........€ s€€dSWEEPs€ <br /> COMPUTER I LOC CODE I DIST CODE AMOUNT RECEIVED j CHECK /CASH I RECEIVED 3Y I DATE RECEIVED - <br /> _ $ s <br /> :::::::::::::::=:::;-;¢___- _�-_ :s:-:-:—__ —: -,:::s=:—:-ss'==-:=:_—s:: :-:__-_. a=_—=—;- _-:--:__::_:-.=.a==-:`:-s:::--:::s:-==s::=.s::= .::::::::::::::::-._. <br /> EH 23 032 (REVISED 5-27-97) <br />