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SAN JOA*LUUNIT PUBLIC HEALTH SERVICES - ENVIRCUMEiIII&HEALTH DIVISION <br /> OERGROUND STORAGE TANK PROGRAM - FEE WORK <br /> S FACILITY SATE NAME1 FACILITY CONTACT NAME <br /> I i� <br /> T <br /> E FACILITY ADDRESS SITE PHONE 0 with AREA CODE <br /> CITY STATE ZIP CODE 1 of TANKS <br /> A 9 at SITE <br /> P <br /> P APPLICANT/ LI AME �� I APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS J APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE I TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX XXXX XXXX XXXX S XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX S XXXXXXXXXXXXX <br /> 1 <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) S170/TANK (After January 1, 1991) <br /> E <br /> X Tanks = 1986 1987 1988 1989 11990 199111992 1993 1994 11995 1996t/t) O 6�/ <br /> F (multiply x y fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX I I Q S Sic) <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX I S <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California N & S Code, Section 25287 <br /> T <br /> Y ;* Tanksx $56.00 1988 through 1990 1991 through 1996 <br /> (Enter mount and year) d 30G/Z 030 /3i <br /> 6 3 6V C2 ge bly, <br /> C PERMANENT CLOSURE (Removal or Authorizedace) TANK I.O. 1(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) N I T NK ) X I S 4. <br /> S (ry <br /> U TEMPORARY CLOSURE (Plan Review & Ins s 96 I T LP a <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hgarjEf3i� 5e idhimm/FACILITY) S .00 mini S <br /> July— Wo <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction +ibivs) T <br /> A PERMIT/SERVICES <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S 6 <br /> R REPAIR FEE (Workplan Review & Construction inspections) TANK I.D. x(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) 0 TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum 3 <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum <br /> H TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> .......:r�:�:nor.fir:».:«.:«:«.:.«::aa:::::.::.-". ..2-•w:«:«.:...e�«.-_».:..:c:�_:�'�«.�»:«:...::.::«:» ;^.«rs...:.. _...«:..»::««._^..:a^z-s:.:..__•_...::...x:.•• »:K::::__.._,.«« •:M 33 <br /> ::::•:::«:i::i:':::�::::ti:::«'::::«5:::::::::::�:«::::'Si:::«::.^.:'»i:::.::«::S•««:5:::«««:::i:.�._..«�.........._....5..�«...��..�..»::^«:5::::«�.._«::�::::::::::'^«::�•tt::'^.«^.:�_�«. — :::5«:�:�::::::J:««:::::«::::« <br /> ^ ,_.x�«�3....2....—.� .. w:.ii_«::•3L::.^«':::«•`•:':«�^:—yism.T.:«:i:::»«::_�I..'�«:.`._':�it:.�^.".«—.�:::.'«::.._"«':� [:..:..L« <br /> SWEEPS I CCMPUTER I I LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK 9/CASH I RECEIVED BY I DATE RECEIVED <br /> If <br /> 3 <br /> ...1.. «_..^.._......1.._ L_ <br /> ......... ........................... fez;^.,rrtu:ac:.. «rr.«. .«::xt«.�.«..._._.._......Yt <br /> ....:...«.«....i....«...._.__..........i..__—«»«.v..._.__...:._.t» «... .....3..—�..__s.a_a-......^...,. C/2 U •�'a«x«r._...ter-.�•::•i_iii'r'eF.�^_ <br />