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SAN JOAUND NTT PUBLIC HEALTH SERVICES - ENVIRORM4EALTH DIVISION <br /> ��� ERGROSTORAGE TANK PROGRAM - FEE 6ORKSH <br /> S#FACILITY <br /> NAME // FACILITY CONTACT NAME <br /> ESS 417 SITE PHONE # with AREA CODE LLAIZ <br /> I TATE ZIP CODE # of TANKS <br /> A L�� at SITE <br /> P <br /> P APPLICANT/BILLING NAME <br /> L APPLICANT CONTACT NAME <br /> I y� p <br /> C MAILING ADDRESS APPLICANT PHONE # 'J[TN AREA CODE <br /> A WITH <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> ------------ <br /> TOTAL <br /> 7986 7987 11988 7989 7990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.Op <br /> A XXXX XXXX I XXXX XXXX (XXX <br /> S XXXXXxxxxxxxX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX I xxxx S XXXXXXXXXXxxx <br /> I <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> F (#multkply # by fee for 11986 1987 11988 11989 1990 1991 11992 1993 1994 1995 1996 �u�iLG«'�VJ� <br /> A each year applicable) XXXX XXXX XXXX I XXXX XXXX �7 I S <br /> C62 0 <br /> I TANK PENALTY FEES ASSESSED XXXX XXxx XXXX I xxxx XXXX _ — S <br /> L _ _ _.__ _ _ .. <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Cade, Section 25287 <br /> T <br /> T # Tanks x 556.00 1988 through 1990 1991 through 7996 <br /> (Enter amount and year) <br /> Vbic� pf1J Jr& �� <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) <br /> L I TANK LD. #(s) <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) I TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) I 5234.00 minimum S <br /> P INSTALLATION PUIN CHECK (Plan Review 3 Construction Inspections) TANK I.O. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = 5624.00 minimum 5 <br /> R REPAIR FEE (Workplan Review 3 Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minin m/TANK) I # TANK(s) X 5234.00 = S <br /> A — <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = 5234.00 minimum 5 <br /> N TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I g <br /> f <br /> S <br /> G CONSULTATION FEE = 578.00/hr I I SAMPLING INSPECTION FEE = 578.00/hr I S <br /> TOTAL DUE S11-3 .3--/ '-3 .� <br /> FOR OFFICE USE ON TOTAL <br /> # COMPUTER # LOC CODE 0[Si CODE I AMOUNT RECEIVED I CHECK #/GSH I RECEIVED BY DATE RECEIVED <br /> • <br />