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SAN JCAQA&COUNTY PUBLIC HEALTH SERVICES - ENVIRONMEN HEALTH DIVISION <br /> GROUND STORAGE TANK PROGRAM - FEE LURK <br /> SI FACILITY ITE NAME I FACILITY C6 CT NAME <br /> I <br /> T <br /> E FACILITY ADDRESS SITE PHONE % with AREA CODE <br /> 8 <br /> CITY STATE ZIP CODE % of TANKS <br /> A at SITE <br /> P. <br /> Post-it°Fax Note 7671 Date pages —3 POSt-it°Fax Note 7671 Datl_'ZI) g pages 3 <br /> ToS� From ! [4 / To C ESQ N L) _/ From ,./ Clad <br /> Co./Dept. Cos 3-G /0'i A. Co./Dept Co. -S <br /> Phone# Phone# _ Phone# Phone <br /> Fax 3 -7Fax3 Zj 6 3 _ Fax tL/3- -73 Zl Fax# 9 6 3 3 3 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = Stoma <br /> A XX%X XX%X XXXX I XXXX XXXX S XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX XXX% XXXX XXXX %XXX s XXXXXXXXXXXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E Tans <br /> F ;multkplY % by fee for 1986 11987 11988 1989 11990 11992 1993 1994 1995 11996 97 <br /> A each year applicable) XXXX XXXX XXXX I XXXX XXXX �i7 /^� I /']p 1707 /70 QZp <br /> Cl <br /> I TANK PENALTY FEES ASSESSED XXXX 11 XXXX I XXXX XXXX XXXX It OI O I / O �7n INI O <br /> I -STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 /v <br /> T <br /> Y % Tanks z 4715-40 WW thruagn 1990 994L� 1 <br /> (Enter amount and year) <br /> y <br /> LI PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.O. %(s) <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) % TANK(s)_ X 5234.00 = 5 <br /> S <br /> U TEMPORARY CLOSURE (P(an Review & Inspections) I TANK I.O. %(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimun/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. %(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.O. %(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) % TANK(s) X 5234.00 = 3 <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minima S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimrm/FACILITY) = S234.00 mini mm S <br /> MI TRANSFER FEE = SZO.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I' <br /> S � <br /> C 1 CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr I 5 <br /> TOTAL DUE S ZQ <br /> FOR OFFICE USE ONLY <br /> SWEEPS %LL COMPUTER % 1 LOC CODE DIST CODE AMOUNT RECEIVED CHECK %/CASH RECEIVED BY I DATE RECEIVED <br /> ii _ <br />