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SAN JOAOUI- INTY PUBLIC HEALTH SERVICES - EMVIRONMENTA ALTH DIVISION <br /> AGROUND STORAGE TANK PROGRAM - FEE WORXSHE. <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> l ^ <br /> T <br /> E FACILIT ADDRESS I SITE PHONE # with AREA CODE <br /> CITY STATE' ZIP CODE # of TANKS <br /> A 1! �\v L 1� I� C1 1., at SITE j <br /> P <br /> P APPLICANT/U/ LLING-TNAME APPLICANT CONTACT NAME <br /> L JLo 1 (10M70 l"C <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A 1 - �'��� r Sj-40 ) V,�s- <br /> N a33 <br /> T CITY i STATEI ZIP COO_E TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX XXXX XXXX 5 XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX XXXX I XXXX XXXX XXXX $ XXXXXXXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = i 1986 11987 11988 1989 11990 11991 1992 1993 1994 1995 11996 I <br /> F (multiply # by fee for <br /> A each year applicable) I XXXX I XXXX I XXXX XXXX I XXXX I I $ <br /> C <br /> II TANK PENALTY FEES ASSESSED XXXX I XXXX I XXXX XXXX I XXXX I I I 15 <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> T # Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) I TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Insoections) TANK I.D. #(s) <br /> R. <br /> El TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)' TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minima/FACILITY) = 5624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FE- = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimus f $ <br /> M TRANSFER FEE _ $20.00 I I UNAUTHORIZED RELEASE EVALUATION = $78.00/hr I $ <br /> I I i <br /> S <br /> C CONSULTATION FEE = $78.00/hr i I SAMPLING INSPECTION FEE = $78.00/hr I S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> --__. --.......... <br /> ..... <br /> .. ........_ <br /> SWEEPS 9 I COMPUTER # I LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK -w/CASH I RECEIVED BY I DATE RECEIVED <br />