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' SAN JOA(ONTY PUBLIC HEALTH SERVICES - ENVIRONM LTH DIVISION
<br /> ERGROUND STORAGE TANK PROGRAM - FEE WOR
<br /> S FACILITY SITE NAME FACILITY CONTACT NAME
<br /> I �f
<br /> T
<br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE
<br /> s c G� LJ C� X04 - 615 t-
<br /> CITY STATE ZIP CODE # of TANKS
<br /> A "G ]r'Z-G/Z/ at SITE =)
<br /> P
<br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME
<br /> L SON c TC-G,t d\JUOa
<br /> C MAILING ADDRESS ^ APPLICANT PHONE # WITH AREA CODE
<br /> A ;VMO —�- >c�{ _ of'fLl g— (2) �.
<br /> N
<br /> T CITY STATE 21P LODE TYPE of APPLICATION
<br /> C (Closure, Installation, etc.)
<br /> TOTAL
<br /> 1986 1987 1988 1989 1990 ow
<br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00
<br /> A XX%X %XX% XX%% X%%X %%XX f XX%%%XX%X%%XX
<br /> O
<br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) X%XX XXXX X%XX XX%% X%XX S XXXXXXXXXXXXX
<br /> I
<br /> V TANK FEE = 550.00/TANK (Prior to January 1,19913 5170/TANK (After January 1, 1991)
<br /> E
<br /> # Tanks = 1986 1987 1988 1989 19901991 1992 1993 1994 1995 1996 570 ,
<br /> F (multiply # by fee for
<br /> A each year applicable) XXXX XXX% %%XX XX%% %XXX S
<br /> L
<br /> 1 TANK PENALTY FEES ASSESSED XXXX %XXX XXX% XXXX XXX% $ 4
<br /> L
<br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 3 5 Code, Section 25287
<br /> T
<br /> Y # Tanks x SSon,Vu g.00 1988 through 1990 1991 through 1996 a(�
<br /> (Enter amount a year)
<br /> S
<br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s)
<br /> L
<br /> 0 CLOSURE FEE = 878.00/hour (3 hours minimum/TANK) # TANK(s)_ X 5234.00 = S
<br /> S
<br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s)
<br /> R
<br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S
<br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s)
<br /> L
<br /> A
<br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = $624.00 mini mum S
<br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s)
<br /> E
<br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) _ x $234.00 = $
<br /> A
<br /> I TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S
<br /> R
<br /> PIPING REPAIR FEE S78.00/hour (3 hours minimm/FACILITY) = $234.00 mini m✓n S
<br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $
<br /> I
<br /> S
<br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr $
<br /> TOTAL DUE S
<br /> FOR OFFICE USE ONLY /I5
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