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SAN JOAtN11N COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH OIYSIgI <br /> Fkc 63(�y <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET a?t3 Q <br /> 5FACIL lTT SITE NAME FAC LITY CONTACT NAME J• <br /> r � , <br /> E FAC( 1TY ADORR" slT PWR with AREA CODE <br /> In IV O — Lo <br /> CITt SJ�Tf� 21P CODE R of TARRS <br /> A &O (,Jf/ et SITE <br /> P <br /> P 7,1911TfIlLUNG NA1E/ PLICANT CONTACT <br /> Ma <br /> C RAlli ADDRESS /n ///� APPLICANT PRIME R WITH AREA CODE <br /> r. <br /> T CITY .n -Ze�v(o\dl✓ M04T STATE 2 -p78 T losure, Ina APPLICATION <br /> etc.) <br /> CF cE oCEI TOTAL <br /> ANNUAL FACILITY FEE (Prior to Jatuery-T v194��C63Qb 1956 1987 198E 19119 1990 <br /> C I SAN JOA SERVICESI y IG, :vim loo s ver. <br /> T FACILITY PENALTY FEES ASSESSED EA <br /> � 'FpAaN 7DOOf X100( <br /> V TANK FEE . %50.00/TANK (Prior to January 1,1991) 5170/TANK (After Joruary 1, 1991) <br /> E <br /> R Tanks . 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply f byty fee for <br /> A each year applicable) //?D ///o S Q <br /> C <br /> I TANK PENALTY FEES ASSESSED )COX )=X n 7 17C % <br /> L <br /> I STATE SURCHARGE . $56.00 each TANK (Due every 5 years) See California N S S Code, Section 25287 <br /> T <br /> T R Tanks A 556.00 1986 through 1990 1991 through 1996 <br /> (Enter recenen <br /> t d year) <br /> LL <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. R(s) <br /> L <br /> 0 CLOSURE FEE • S78.00/hour (3 hours minfasm/TANK) R TANK(s) X 5234.00 S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review d inspections) TANK I.D. S(a) <br /> R <br /> E TEMPORARY CLOSURE FEE . 578.00/hcur (3 hours minimua/FACILITT) m 5234.00 minimum S <br /> P INSTALLATION PUN CHECK (Plan Review S Corot ruction Inspections) TANK I.D. A(a) <br /> L <br /> A <br /> N PLAN CHECK FEE • S78.00/hour (8 houn minfasm/FACILITY) . 5624.00 mini asm S <br /> R REPAIR FEE (Workplan Review L Construction Inspections) TANK I.D. 9(a) <br /> E <br /> P TANK LINING REPAIR FEE . S78.00/hour (3 hours mininAa/TANK) Al TANKW X 5234.00 * S <br /> A <br /> I TANK RETROFIT REPAIR FEE • 578.00/hour (3 hours win./FACILITY) . %234.00 minium f <br /> R <br /> PIPING REPAIR FEE . 178.00/hour (3 hours mfnhmm/FACILITY) . 9234.00 minimus S <br /> N TRANSFER FEE a 120.00 IMAUTNCQIZED RELEASE EVALUATION . 578.00/hr S <br /> I <br /> C CONSULTATION FEE . 979.00/hr SAMPLING INSPECTION FEE . 578.00/hr S <br /> TOTAL DUE 1 <br /> FOR OFFICE USE ONLY <br /> �tiiT�-M)✓,a�i.���eIt�aa�»��A�I�rem��am}������w�w����AY A a t� �I Air�O <br /> �1RfAaw�llrassY el.�Ia%aeemtmwaM rj�Ml.wMw#a{M�.i�tAfNil�IseOYale� 'MMM raMf.rwrw M;Y%�f1r�aia <br /> EN 23 032 (REVISED 3-1-931 `v psae 11 <br />