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SAN JOAC ;Y PUBLIC HEALTH SERVICES - ENVIRONME_ TH DIVSION <br /> UnvCRGROUND STORAGE TANK PROGRAM - FEE NORKSHEEi <br /> S FACILITY SITE AME I FACI TY CO T NAME <br /> T <br /> E FACILITY A40BESSSITE PHONE 1. with AR A CODE <br /> &I \�.zy `V�` <br /> CITY ATEI � ODE of TANKS <br /> - b <br /> Al � 3 at SITE <br /> P <br /> PI APPLICANT/BIL N MECANT ON CT NAME <br /> LI <br /> I <br /> CI MAILING ADDRESS I APP CANT PHONE TH AREA CODE <br /> A <br /> N <br /> TEI P �D-E,� ( TYPE of APPLICATION <br /> TI � (Closure, nsta at etc.) <br /> TOTAL <br /> j 1986 11987 11988 1989 1990 <br /> Al ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> XXXX I XXXX XXXX I 15 <br /> Tj FACILITY PENALTY FEES ASSESSED (If Appiicable) I XXXX I XXXX I XXXX I I $ <br /> 1 <br /> V1 TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> EI g Tanks = 1986 ( 1987 11988 11989 11990 i 1991 1992 11993 11994 11995 11996 I <br /> FI (multiply 1 by fee for <br /> AI each year applicable) XXXX I XXXX i XXXX I ! ! I I I I I 1 5 <br /> i ! <br /> Ii TANK PENALTY FEES ASSESSED XXXX I XXXX I XXXX I i , ! I I I i S <br /> LI <br /> II STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> Ti <br /> YiTanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> CI PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. :(s) <br /> IL <br /> 01 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) T TANK(S) X 5234.00 = S <br /> S' <br /> Ul TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. :(S) <br /> ETEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) , $234.00 minimum , S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. 9(s) <br /> OoAiL <br /> NJ PLAN CHECK FE. = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum 5 <br /> i <br /> RI REPAIR -FEE (Workplan Review & Construction Inspections) TANK I.D. l(s) <br /> E <br /> P! TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) I TANK(s) x $234.00 = S <br /> A <br /> 1; TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum I S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> MI TRANSFER FEE = S20.00 I I UNAUTHORIZED RELEASE -EVALUATION = S78.00/hr I I S <br /> S ' <br /> ClCONSULTATION FEE= = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr ! S <br /> TOTAL DUE S 2 <br /> FOR OFFICE USE ONLY __...._.__ _.___.__._____ _,•• _.........._ <br /> __€ _:___€€sii _s__ € " _`€-_:r= ::sc a`_ =st: tt:ta_ _ ::•• =_r__ <br /> SWEEPS 9 I COMPUTER 9 LOC CODE I DIST CODE I AMOUNT RECEIVED CHECK -�/CASH ! RECEIVED 3Y ! DATE RECEIVED <br /> ! ! _ <br /> 5 ! _ <br /> _..._...................__.................._.......... _.............. <br /> _.. ............._......._............ <br /> .............-...::._.............-....................-...................._...-.-......................._.._.............._._.._...........__.......__.._...................._..................................................................._...._............................_..... _::........_ <br /> �H 23 032 (REVISED 4-29-94) <br />