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SAN J(YAZJIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE DIVSION <br /> IROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T -To 5C C\ t � SIhIN5il&-R1 <br /> 'E FACILITY ADDRESS ITE P NE # with AREA CODE <br /> & 5 — b s� a CZ0� 83- U3s � <br /> CITY STATE ZIPCODE # of TANKS <br /> P l U C� J o�, t at SITE <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> � <br /> A S LV -L= ,E <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N sv L 44.4 <br /> ' zv �� s - X <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> L (Closure, Installation, etc.) <br /> L41 L\?, <br /> TOTAL <br /> 1986 11987 1988 1989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX I XXXX XXXX XXXX I XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX I XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1988 11989 1990 1 1991 1992 1993 1994 1995 1996 1997 11998 <br /> F (multiply # by fee for <br /> A each year applicable) XXXXF—XXXX <br /> I XXXX XXXX XXXX i S <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX XXXX XXXX XXXX I I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 S <br /> T <br /> Y # Tanks x $8.00 1988 through 1993 (S56) 1993 through 1997 ($56) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY 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. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.O. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/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) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> N TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr 5 <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> .____......_.._.........M.._.............._........ ...._�_..._ _.... ___.....__....._._.._.. :_- - - - _......... . <br /> - SWEEPS # COMPUTER # I LOC CODE DIST CODE AMOUNT RECEIVED I CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> :15 <br /> - �.....__...__....._.__.. _____. _.. — ----..._._ _.. :._.. <br /> ��. <br /> EH 23 032 (REVISED 1-12-98) <br />