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� A <br /> 4 SAN JOACCOUNTY PUBLIC HEALTH SERVICES - ENVIRON <br /> EALTH DIVISION <br /> ERGROUND STORAGE TANK PROGRAM - FEE WORKS <br /> 5 FACILITY SITE NAME _ FACILITY CO ACT N E <br /> IT �6 r / r G� <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & S� a a to <br /> A CITY j�� !� CSF <br /> E Z CODE # of TANKS <br /> T t/ ITL at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION I/rc- <br /> (Closure, Installation, etc.) (/ <br /> TOTAL <br /> 1986 1987 1 1988 1 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) 5100.00 <br /> A XXXX xxxx XXXX XXXX X)= S XXXXXxxxxxxxX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx XXXX XXXX XXXX XXXX S XXXXXXXXXXXXX <br /> I A <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1 1986 1 1987 1988 1989 1990 1991 1992 1993 1994 1 1995 1996 <br /> F (multiply # by fee for <br /> Aeach year applicable) XXXX XXXX XXXX xxxx XXXX 170 l 70 1/ 70 11 o a <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx XXXx XXX)( XXXX XXXX 0 1 D V/� j /�10 S <br /> L t V <br /> I STATE SURCHARGE = $56.00 each TANK D e eve e r See California H & S Cade, Sect i 25287 �. <br /> T <br /> Y # Tanks_ x 556.00 <br /> (Enter amount and year) FE <br /> 5 2�f- 5 . <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) 1 TANK I.O. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) 1 Al TANKWs X 5234.00 = _. <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) 1 TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.001hour (3 hours minim=/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 = 578.00/hour (8 hours minimm/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (workplan Review & Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) x 5734.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 4234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimus/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I 1 S <br /> I <br /> 5 <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE i <br /> FOR OFFICE USE ONLY V <br /> a SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED I CHECK #/GSH RECEIVED SY I DATE RECEIVED <br /> -.....,._._..__._.1.._..._.....__._ C5 . .� 0 5. . <br />