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SAN J13At111IN COUNTY PUBLIC HEALTH SERVICES - ENVIRCNMENTAL HEALTH 7IVSIOM <br /> • <br /> Hwn99dhWQ TORAGE IANK PROGRAM - FEE 110RKSHEET <br /> Maw <br /> IirAC:LiY SITE ^ IFACfLIT7 CONTACT NAME <br /> i � yy <br /> T <br /> EI FACILITY ADDRESS SITE PHONE I" With AREA CCOE <br /> W MMDR,10b , <br /> CITY /I A EE ZIP CCCE of TANKS !� <br /> A � at SITE ...La <br /> P <br /> P APPLN1 T/9[LLING NAME �1 � � APPLICANT NAME <br /> I <br /> L U Vim`Fp"c7 <br /> C .4AIL!NG ADDRESS AF ICANT PHONE .: WITH AREA CCOE <br /> N II t.if cjr`.""1�C� <br /> T CITY 1 STATE Z C0011 I TY c of ,P ristATLat <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 � 1987 I T988 1989 1990 <br /> ANNUAL FACILITY r_= (Prior to Januar-y 1, 1991) = 5100.00 4 <br /> A } XXXX XXXX I XXXX XXXX I XXXX I 5 XXXXXXXX <br /> e" f <br /> TI FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX I XXXX I XXXX I XXXXI XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) I 4170/TANK (After January 1, 1991) <br /> Tanks = 1988 1989 1990 1491 1992 1943 1994 1995 1496 199T 1998 <br /> 'r (multiply + by fee or <br /> Aj each year applicable) XXXX XXXX XXXX l XXXX lxxxx ' S <br /> C' <br /> I TANK PENALTY FEES ASSESScJ I XXXX XXXX XXXX I XXXX XXXX I I 5 <br /> La <br /> I STATE SAJRCHARGEE FCR NE'a FACILITIES ONLY=318.30 5 <br /> T <br /> YI Tanks x 53.00 1988 through 1993 (556) 1993 through 1997 (S56){ 1998 <br /> SURCHARGF FOR 1998 I XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX 5 <br /> C'j ?cRMANENT CLOSURE (Removal or authorized Closure-in-Place) TANK I-D. T(s) <br /> i <br /> L'i i <br /> O CLOSURE FEE = '578.00/hour (3 hours minimum/TANK) 1 TANK(s) A— X 5234.00 = 3 5 <br /> S <br /> UI TEMPORARY CLOSURE (PLan .Review 3 inspections) 1 TANK I.0. l(s) <br /> EE i"cMPCRARY CLOSURE r"""e- = 5Xm <br /> 3.00/hour (3 hours minimum/FACILITY) s734.00 minimum5 <br /> PE !NSTALL-ATION PLAN CHECK (Plan Review 3 Construction Inspe;tions)I TANK I.0. :(s) <br /> L' <br /> A <br /> N FLAN CHECK FEE = 378.00/hour C8 hours minim/FACILITY) = 5624.00 minimum S <br /> R! .REPAIR FEE (Workptan Review 3 Canstruction (nspections) TANK E.D. #(s) <br /> Cl <br /> PI TANK LINTNG REPAIR FEE = 578-CG/hour (3 hours minimum/TANK) I TANK(s) X SZ34.00 = S <br /> A <br /> [ TANK .RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.CO/hour (3 hours minimum/FACILITY) = 5234.00 minimum 1 S <br /> MI TRANSFER rEc = 520.00 I UNAUTHORIZED RELEASEE E`IALUATICN = 578.00/hr � � 15 <br /> S' <br /> Cl CCNSULiATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = s78.001hr I 5 <br /> TOTAL WE 5 <br /> FM OFFICE USE ONLY <br /> St4EEPs-1 T�~YCOMPUTER I I LOC CODE I GIST CCDE I�AMCUNT RECEIVED I CHECK ;'/GASH I RECZEVED 3Y GATE RECEIVED - <br /> EH <br /> 23 032 (REVISED 1-12-98) <br />