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SAN JOAOUI*TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL) LTH DIVSION <br />ERGROUND STORAGE TANK PROGRAM- FEE yORKSH <br />C <br />S <br />I <br />T <br />FACILITY SITE NAME I <br />hn l! <br />FACILITY CONTACT NAME <br />C/_1 <br />A <br />N <br />E <br />& <br />FACILITY ADDRES <br />a000 S-hrl9so x, �� <br />SITE PH E # with AREA CODE <br />C ao9� 98.3 <br /># TANK(s) X 5234.00 = S <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />A <br />CITYO <br />STATEI <br />I/77 <br />ZIP CODE <br />C�Q �p <br /># of TANKS <br />at SITE <br />5234.00 minimum S <br />P <br />= S234.00 minimum <br />S <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum <br />S <br />P <br />L <br />I <br />APPLICANT/BILLING CANT/BILLING NAME <br />UE &h Ce kl C)ov <br />APPLI NT CONTACT NAME <br />CCC K) <br />$ <br />S <br />C <br />N <br />MAILING ADDRESS <br />APPLICANT HONE #WITH AREA CODE <br />C C/ /6 939-9Igq <br />S <br />FOR OFFICE USE ONLY <br />€ €__ <br />SWEEPS COMPUTER LOC CODE DIST CODE AMOUNT RECEIVED <br />I I I <br />TOTAL DUE <br />-r s =.....—=::............:=: ................ :s:::::::::w~ <br />CHECK RECEIVED BY I <br />S <br />DATE RECEIVED <br />5 <br />I I <br />T <br />CITY�J <br />STATE <br />ZIP CODE <br />2 <br />TClosur Installation, etc.) <br />TOTAL <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX S XXXXXXXX <br />A <br />C <br />T <br />I <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX 5 XXXXXXXX <br />V <br />TANK FEE _ $50.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br /># Tanks = <br />1987 <br />1988 <br />1989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1994 1995 <br />1996 <br />1 1997 <br />F <br />(multiply # by fee for <br />XXXX <br />XXXX <br />XXXX <br />XXXx <br />XXXX <br />S <br />A <br />each year applicable) <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />I <br />S <br />L <br />I <br />T <br />STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 i5 <br />Y <br /># Tanks x $8.00 <br />1988 through 1990 (S56) 1991 through 1996 (S56) <br />1997 <br />SURCHARGE FOR 1997 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX <br />S <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minima /FACILITY) <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = S <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />P <br />A <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum S <br />P <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)TANK <br />I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minima /FACILITY) <br />= S624.00 minimum <br />5 <br />R <br />E <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />P <br />A <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = <br />$ <br />I <br />R <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />= S234.00 minimum <br />S <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum <br />S <br />M <br />I <br />TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr T <br />$ <br />S <br />C <br />CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br />= S78.00/hr ' <br />S <br />FOR OFFICE USE ONLY <br />€ €__ <br />SWEEPS COMPUTER LOC CODE DIST CODE AMOUNT RECEIVED <br />I I I <br />TOTAL DUE <br />-r s =.....—=::............:=: ................ :s:::::::::w~ <br />CHECK RECEIVED BY I <br />S <br />DATE RECEIVED <br />5 <br />I I <br />EH 23 032 (REVISED 5-27-97) <br />