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P <br />L <br />I <br />C <br />A <br />N <br />T <br />SAH JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />UNDERGT I STORAGE TANK PROGRAM - FEE UORKSHEET <br />iTY SITE NAME <br />q / <br />F T�ONTIA�N <br />CT <br />1988 <br />'ILITY ADDRESS <br />�, <br />SITE PHONE x with AREA CODE <br />f� . <br />S <br />CITY ( <br />STATE <br />ZI CODE <br /># of TANKS <br />XXXX XXXX <br />TEMPORARY CLOSURE (Plan Review b Inspections) <br />TANK I.O. #(s) <br />at SITE <br />APPLICA T/8fLLIN NAME <br />APPLI NT CONTACT N E <br />LING ESS J <br />APPLICANT PHONE # WITH AREA CODE <br />CI�f <br />STATE <br />-A <br />ZIP CODE <br />TYPE of APPLICATION <br />(Closure Installation <br />�G <br />T <br />_ <br />On <br />xXXX I XXXX <br />etc <br />l <br />C <br />?ERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />1986 1987 <br />1 <br />1988 <br />1989 1990 <br />0 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) - S100.00 <br />k TANK(s) X 5234.00 - <br />- <br />S <br />S <br />TOTAL DUE <br />A <br />XXXX XXXX <br />TEMPORARY CLOSURE (Plan Review b Inspections) <br />TANK I.O. #(s) <br />R <br />S <br />C <br />E <br />TEMPORARY -CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimun <br />S <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />xXXX I XXXX <br />I <br />I <br />S <br />V <br />TANK FEE = S50.00/TANK (Prior to January 1,1491) <br />5170/TANK (After January 1, 1991) <br />E <br />0 Tanks = <br />1986 <br />1987 <br />1988 11989 11990 <br />1991 11992 1993 <br />1994 11995 11996 <br />F <br />(multiply # by fee for <br />A <br />each year applicable)XXXX <br />xXXX <br />I <br />I <br />C <br />I <br />I <br />S <br />I <br />TANK PENALTY FEES ASSESSED <br />I XXXX <br />XXXX <br />L <br />I <br />STATE SURCHARGE = S56.00 each TANK (Due every 3 years) See California H 3 S Code, Section 25287 <br />T <br />Y <br /># Tanks x 556.00 <br />1988 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />S <br />C <br />?ERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. 1(s) <br />L <br />0 <br />CLOSURE FEE = 278.00/hour (3 hours minimun/TANK) <br />k TANK(s) X 5234.00 - <br />- <br />S <br />S <br />TOTAL DUE <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review b Inspections) <br />TANK I.O. #(s) <br />R <br />E <br />TEMPORARY -CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimun <br />S <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. »(s) <br />L <br />A <br />N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />RI REPAIR FEE (Workplan Review 3 Construction Inspections) <br />EI <br />PI TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br />A <br />I <br />RTANK RETROFIT REPAIR FEE = 278.00/hour (3 hours min./FACILITY) <br />IPIPING REPAIR FEE - S78.00/hour (3 hours minimum/FACIL[TY) <br />TANK I.O. #(s) <br /># TANK(s) X 5234.00 = <br />• 5234.00 minimun <br />• 5234.00 minimum <br />S .T-ivU. o iy3`il <br />MI <br />I <br />TRANSFER FEE - S20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />S <br />C <br />CONSULTATION FEE - S78.00/hr <br />I SAMPLING INSPECTION FEE = S78.00/hr <br />S <br />TOTAL DUE <br />S <br />FOR OFFICE USE ONLY <br />-- <br />SWEEPS # I COMPUTER x I LOC CODE I DIST CODE I AMOUNT RECEIVED CHECK k/CASH I RECEIVED 3Y I DATE RECEIVED <br />EH 23 032 (REVISED 10-28-93) 3 Y <br />