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/ TOTAL <br />SAN JOACUINAWTT <br />PUBLIC HEALTH SERVICES - ENVIROMMENTALAWTH DIVSION <br />GROUND STORAGE TANK PROGRAM - FEE <br />11990 <br />WORKSN <br />SI <br />FACILITY SIT NA E <br />' <br />FACILIT TACT NAME <br />( XXXX I XXXX <br />T� <br />XXXX <br />S <br />XXXXXXXX s <br />% <br />1 <br />B <br />EI <br />FACILITY ADDRE S <br />( SITE PHONE # wish AREA CODE E <br />T FACILITY PENALTY FEE: ASSESSED ('.f Applicable) <br />XXXX j XXXX <br />j XXXX j XXXX <br />sP� <br />S <br />XXXXXXXX <br />I <br />CITY <br />j ATE 1 Z CODE j of TANKS q <br />Ai <br />at SITE <br />5170/TANK (After <br />P <br />F' <br />P! <br />APPLICAN I _jN NAM/j�° <br />1� APPL T CONTAST NAME i <br />�' Tanks = 1987 j 1988 1 1989 1 1990 1991 <br />': 1992 1993 1994 <br />1995 1996 <br />'CL <br />a <br />I� <br />p <br />C' <br />MAILING ADDRESS <br />f <br />I ; <br />APPLICANT PHONE # WITH AREA CODE <br />162 <br />{ <br />Nj <br />i <br />T <br />C:TY U Y2 <br />s <br />,ATE; ZI COD,E TYPE or APPLICATION <br />i (Closure, Installation, etc.) <br />/ TOTAL <br />NI TRANSFER FEE _ $20.00 , I UNAUTHORIZED RELEASE EVALUATION = $78.00/hr ; S i <br />SI <br />C CONSULTATION FEE = S78.00/hr ' ( SAMPLING INSPECTION FEE = S78.00/hr ( I S <br />I <br />TOTAL DUE S <br />FOR OFFICE USE ONLY <br />- -- :,__ : :- -•- ::_st_ ° a-: _--_ = =-- == _ = — -:___ �_ s:_was:¢.--__ _ ::-- = •—.= =:__ _•: <br />SWEEPS # COMPUTER i LOC CODE DIST CODE ( AMOUNT RECEIVED , CHECK #/CASH - 'RECEIVED 3Y <br />EH 23 032 (REVISED 5-27-97) <br />DATE RECEIVED <br />1986 1987 <br />1 1988 i 1989 <br />11990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br />' <br />Al <br />( XXXX I XXXX <br />XXXX XXXX <br />XXXX <br />S <br />XXXXXXXX s <br />C <br />1 <br />B <br />T FACILITY PENALTY FEE: ASSESSED ('.f Applicable) <br />XXXX j XXXX <br />j XXXX j XXXX <br />! XXXX <br />S <br />XXXXXXXX <br />I <br />- <br />V' TANK FEE = S50.00/TANK (Prior to January 1,1991) <br />5170/TANK (After <br />January 1, 1991) <br />F' <br />�' Tanks = 1987 j 1988 1 1989 1 1990 1991 <br />': 1992 1993 1994 <br />1995 1996 <br />11 1997 <br />a <br />F (multiply T by fee for <br />p <br />Al each year applicable) XXXX XXXX ; XXXX , XXXX :XXXX <br />I ; <br />{ <br />S <br />i <br />I': TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX <br />I <br />j <br />$ <br />: <br />L' <br />I; STATE SURCHARGE FOR NEW FACILITIES ONLY = S18-50 <br />p$ <br />a <br />T' <br />Y; # Tanks x 58.00 1988 through 1990 (S56) <br />1991 through <br />1996 ($56) 1997 <br />SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XXXXXXXXXXXXXXXXXXXXXXX <br />S <br />CI PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) <br />I TANK i.D. #"(s) <br />a <br />L: <br />01 CLOSURE Fc_ = 578.00/hour (3 hours minimum/TANK) <br />R TANK(s) X <br />5234.00 = <br />S <br />Si <br />' <br />UI TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R' <br />E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />I 5234.00 minimum <br />S <br />Pil INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)i TANK I.D. #(s) <br />L' <br />A( <br />NI PLAN CHECK FEE = $78.00/hour (8 hours minimun/FACILITY) <br />= S624.00 minimum <br />5 <br />s <br />NI TRANSFER FEE _ $20.00 , I UNAUTHORIZED RELEASE EVALUATION = $78.00/hr ; S i <br />SI <br />C CONSULTATION FEE = S78.00/hr ' ( SAMPLING INSPECTION FEE = S78.00/hr ( I S <br />I <br />TOTAL DUE S <br />FOR OFFICE USE ONLY <br />- -- :,__ : :- -•- ::_st_ ° a-: _--_ = =-- == _ = — -:___ �_ s:_was:¢.--__ _ ::-- = •—.= =:__ _•: <br />SWEEPS # COMPUTER i LOC CODE DIST CODE ( AMOUNT RECEIVED , CHECK #/CASH - 'RECEIVED 3Y <br />EH 23 032 (REVISED 5-27-97) <br />DATE RECEIVED <br />