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SIN JOAOUIN COUlIC HEALTH SERVICES - ENVIRONMENTAL HEAL �VS ION <br />LW <br />Ek UND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SIT NAME <br />FACILITY CONTACT NAME � G <br />1987 <br />1988 <br />1989 <br />E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />ANNUAL FACILITY FEE (Prior to Jamary 1, 1991) - 5100.00 <br />5 �(c� <br />r - Z67 <br /># TANK(s) _ X 5234.00 = <br />CITY <br />STATE <br />ZIP CODE <br />/� <br /># of TANKS <br />SITE <br />A <br />♦ <br />�t <br />95•• <br />at <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimus <br />O h <br />C <br />T <br />.J(o <br />XXXX <br />P <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />�//� <br />l,/a ///C! <br />4 N9 L <br />I <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />AOO <br />8o1 <br />-44 'WC <br />N <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />A <br />f 5 3es G I <br />(Closure, Installation, <br />it/ <br />TOTAL <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />1966 <br />1987 <br />1988 <br />1989 <br />1990 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br />A <br />ANNUAL FACILITY FEE (Prior to Jamary 1, 1991) - 5100.00 <br />PLAN CHECK FEE - 578.00/hour (8 hours minimus/FACILITY) = 5624.00 minimum <br />i <br /># TANK(s) _ X 5234.00 = <br />5 <br />S <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimus <br />R <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s)_ X 5234.00 = <br />5 <br />S <br />S <br />1 <br />V <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br />0 Tanks <br />1986 <br />1987 <br />1988 <br />1989 <br />7990 <br />1997 <br />1992 <br />7993 <br />1994 <br />1995 <br />1996 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) <br />S <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXXXXXX <br />S <br />L <br />I <br />STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T <br />Y <br /># Tanks x $56.00 <br />1986 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />S <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) Z X $234.00 = <br />S C� <br />PLAN CHECK FEE - 578.00/hour (8 hours minimus/FACILITY) = 5624.00 minimum <br />i <br /># TANK(s) _ X 5234.00 = <br />5 <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimus <br />R <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s)_ X 5234.00 = <br />5 <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE - 578.00/hour (8 hours minimus/FACILITY) = 5624.00 minimum <br />i <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK 1.0. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) _ X 5234.00 = <br />5 <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimus <br />S <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimua/FACILITY) = $234.00 mini mm <br />S <br />TRANSFER FEE = $20.00 <br />I <br />TATION FEE = 278.00/hr <br />FOR OFFICE <br />UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />SAMPLING INSPECTION FEE <br />SWEEPS # I COMPUTER # I LOC CODE I DI <br />6 5 Z <br />EH 23 032 (REVISED 11-1-92) <br />- 578.00/hr <br />CHECK #/GSH <br />Page 11 <br />S <br />S <br />TOTAL DUE S <br />RECEIVED BY DATE <br />