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SAN JOAOUINPUBLIC HEALTH SERV,CES <br />UMD OUND STORAGE TANK PROGRAM ENVIRONMENTAL REALODIVS10M <br />SI FACILITY SITEY NAME FEE WORKSHEET <br />r i�"b5 VIVS �VrvR)st FA(fJ�I LITY CONTACT NIAAmEE1 <br />r. FACILITY ADDRESS <br />( C Cyy ,'J'b (J �1-- SITE PHONE X w{th AREA CODE <br />CIT 0 - 59 -37)5- <br />S ATE ZIP CODE M of TANKS <br />R APPLICANT/BILLING NAME at 9s366 at SITE CF) 3-(,�J-n pfa2T)rE <br />L <br />I 6 r)% APPLICANT CONTACT NAME <br />C HAILING ADDRESS <br />A % <br />% - APPLICANT PHONE Y WITH AREA CODE <br />v — <br />r <br />CITY <br />'no � f STATE 2}�' CODE TYPE of APPLICATION I NSTAL T) <br />75 3rj (Closure, Installation, etc.) O n/ <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) s 5100.00 <br />A <br />1986 <br />1987 1988 <br />C <br />1989 1990 <br />T FACILITY PENALTY FEES ASSESSED (If <br />Applicable) <br />V TANK FEE 550.00/TANK <br />X)= <br />XKKX <br />E (Prior to January 1,1991) <br />" Tanks <br />986 <br />5170/TANK <br />(After January 1 1991) <br />1987 1988 1989 <br />tiply s by fee for <br />a <br />1990 1991 1992 <br />each year applicab(e) <br />1993 1994 1995 1996 <br />C <br />I TANK PENALTY FEES ASSESSED XXXX <br />l XXXX <br />STATE SURCHARGE = 556.00 each TANK <br />(Due every 5 years) ) <br />" x Tanks x 556.00 <br />See California R d S Cade, Section 25287 <br />(Enter amount and1986 through 199n <br />- --- <br />"' <br />1991 <br />through 1996 I <br />C PER CLOSURE (Removal or Authorized Closure-in-P(ace) <br />L TANK I.D. $(a) X <br />C CLOTURE FEE a 278.00/hour (3 hours miniRnnVTAHK) <br />U TEMPORARY CLOSURE (Plan Review d Ins hf iAHK(s)� X $234.00 <br />R pectians) TANK J.D. tf(S) <br />TEMPORARY CLOSURE FEE ` 578.00/hour (3 hours mini <br />num/FACILITY) a 5234,00 minimum <br />P INSTALLATION PLAN CHECK (Plan Review d Construction Ir>spections) TANK I.D. <br />a <br />L <br />A <br />N PIAN _ CHECK FEE 578.00/hour (8 hours minimuNFACILITY) <br />r_r-----�— a (624.00 minimum <br />?I REPAIR FEE (Workplan Review d Coretruction Ins <br />A LI Petitions) <br />TF1RR FEE a 578.00/hour (3 hours minimxm/TANK) <br />RI TOFIT REPAIR FEE a 178.00/hour (3 hours min./FACILITY) <br />RPPAIR FEE a 178.00/hour(3 ho' minimun/FACILITY) <br />H I TRANSFER FEE a 520.00 <br />I <br />S---�.���_. <br />C CCNSUI TATICN FEE a f78.00/hr <br />TANK 1.0. #(S)-- <br />M TANK(s) �_ X 5234.00 = <br />' 5234.00 minimus <br />2234.00 minimum <br />UNAUTHORIZED RELEASE EVALUATION m 578, D p/hr <br />SAMPLING INSPECTION FEE <br />= 178.00/hr <br />FCR OFFICE USE CNi r Tnru <br />TOTAL <br />s <br />S <br />