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SAN JOAOUI NTY PUBLIC HEALTH SERVICES - ENVIRONMENTLTH DIVSION <br /> ERGROUND STORAGE TANK PROGRAM - FEE YORK* <br /> SI FACILITY SiT NAME / I FACILITY CONTACT NAME <br /> I <br /> T <br /> EI FACILITY ADDRESS I SITE PHONE # with AREA CODE <br /> CITY j TATE; ZIP CODE i # of TANKS N <br /> pI (a , at SITE <br /> Pi APPLICANT/ ILLING NAi2z:6�— <br /> APPLICANT CONTACT NAMEIV' W <br /> AI MAIL 3 ^�ADDRESS \ � � APPLICANT PHONE # WITH AREA CODE <br /> N A A G 33 Z � <br /> Tj CITY'd <br /> STATE ZIP CODE TYPE of APPLICATION <br /> C�,S i (Closure, Installation, etc.) <br /> TOTAL <br /> _ - 1986 1 1987 1988 1989 1990 K <br /> .. __ a <br /> ANNUAL =ACI"- 'Y (Prior to January 1, 1991) = 5100.00 ' <br /> A! j xxxx xxxx xxxx xxxx xxxx S xxxxxxxx <br /> a T! FACILITY PENALTY r-EES ASSESSED (If Applicable) i XXXX I XXXX XXXX XXXX XXXX S XXXXXXXX <br /> e I; ii <br /> p VI TANK FC_ = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> 9 E' <br /> F! Tanks = 1987 i 1488 1984, x' 1990 1991 1992 t993 1994 1995 1996 1997 <br /> Cmultipiy # by fee for <br /> g Ai each year appiicabie> xxxx xxxx xxxxXXX I I wS N <br /> C! <br /> I; TANK PENALTY FEES ASSESSEDXXXX XXXX XXXX XXXX iXXXX ! ( 5 <br /> L' <br /> Ti STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 �S <br /> Y Tanks x 58.00 1988 through 1990 (S56) 1991 througn 1996 (S56) 1997 it <br /> 9 <br /> ! SURCHARGE FOR 1997 xxxxxxxXXXXXXXXXXXXXXXXXXXX -- XXXXXXXXXXXXXXXXXxxxxxx q S o <br /> Ci PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) ) TANK 1.D. #(s) <br /> L! qq <br /> 01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) i. # TANK(s) X S234.00 = q S <br /> Si && <br /> UI TEMPORARY CLOSURE (Plan Review & Insoections) TANK I <br /> R! .D. #(s) <br /> El TEMPORARY CLCSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br /> P, INSTALLATION PLAN CHECK (Plan Review & Construction Insaections)i TANK I.D. #(s) <br /> L <br /> AlNi PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> RREPAIR FEE (Workplan Review & Construction Inspections) i TANK I.D. #(s) <br /> E <br /> PI TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ <br /> A I � <br /> II TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S 3 <br /> MI TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I 5 <br /> I <br /> SI <br /> C. CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> ':_=............. = =-::ass-::__- : ` ...........i': s € <br /> SWEEPS # COMPUTER # I LOC CODE I DIST CODE I AMOUNT RECEIVED CHECK #/CASH RECEIVED 3Y_ I DATE RECEIVED _ <br /> EH 23 032 (REVISED 5-27-97) <br />