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SAN JOAflU%NTY PUBLIC HEALTH SERVICES - ENVIRONMENTOLTH DIVISION <br /> GROUND STORAGE TANK PROGRAM - FEE WORKSH <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> // IMIK I 'I/JC:2 `j(Z,LK l�il��� 1� "Zau �,a -� <br /> T r SPE PHONE # with AREA CODE <br /> E FACILITY ADDRESS <br /> CITY 2,oq) ` q 3-,3213 <br /> & STATEJ ZIP CODE # of TANKS <br /> A [�WDA I�-cc r~► G 4 �TSZo� at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L �u �2SG'J n+§'r+1 :c ^+ W'�q.vc <br /> I <br /> C MAILING ADDRESS PLI ANT PHONE # WITH AREA CODE <br /> A2,3 w � - s� T== r �2-P-q) 9 3sv5 <br /> N <br /> F CITY STATE ZIP CODE TYPE of APPLICATIONe�2 <br /> (;C krt'.-,j Cil c/.52 (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A %XXX xXXX XXXX XXXX XXXX S XXXX%XX%XXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXX% $ XXXXXxxxxxxxx <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX Xxxx XXxx XXXX XXXX $ <br /> C <br /> I TANK PENALTY FEES ASSESSED xXxx Xxxx XXXX XXXX Xxxx $ <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C'. PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = 5 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum 5 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A C L' <br /> I TANK RETROFIT REPAIR FEE = 578,00/hour (3 hours min./FACILITY) = $234.00 minimum 5 ,3 <br /> R' <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE $ ��ac <br /> FOR OFFICE USE ONLY <br /> = SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED = <br /> 5 <br /> ........::.— <br /> :.•:.._.::::�:::--_;.�.:.:;::::::€:::era::::::.=.-a:,:-�:•-----•—=�:::::.-�..�:�::_��:-:::::::::::_�-::_.-:::::::::::�.•�:�::�.. .__._.._. . _._�::��:-- <br />