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.. SAN JOAOUINAWTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL LTH DIVISION <br /> ROUND STORAGE TANK PR - FEE YORKSHE <br /> S FACIiITY SITE NAME FAC14,KY CONTACT NAME <br /> I 'Yk HFAI <br /> T i <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & Sol " IM In. 141 <br /> Cm TATE Z CODE # of TANKS <br /> A r at SITE <br /> P <br /> P APPLICANT/BILLING NAM LICANT CONTACT N E <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N 1 <br /> T ATATE �, ETYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 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) XXXX XXXX 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 = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum 5 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum 5 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum $ E� <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr $ <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY <br /> __ _._ _.»;;»»:;»........._.»......:......:;.:.._;»»;......;M___»_. ...._» m .;» .;__.. .............. :n.. <br /> »..................: r-.-a.. _._--»..»» _._. _:._•_ ...... :. ::.......:..................._.................::::-........- <br /> ::: .:-:..............._......_» :.. W_ __.._.........._ ...................................._.._........_.........._ _..._...._ .__- ::-: ::::-:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.::...................�.».._. <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> $ <br /> ................_.. ..»..._»._»....»......».......»_....»...._................................................................................».»....._......._.._......»......»..._......»...�..-._...................,...........;............................,......................................._.»..- <br /> ......_...........»...»......y.;:..•-.............................................................................:s.^:::•.a:::s:::.:.:::r..::::::c::::r..r.:::»::::::..:.:::.:::::::::::::.......................................... <br /> 1 <br />