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C <br />L <br />SAH .10ACUIN COUNTY "LIC HEALTH SERVICES - ENVIRONMENTAL HEALTH 0IVSION <br />UNDERGR' ` STORAGE TANK PROGRAM - FEE WORKSHEET <br />TANK I.D. »(s) <br />0 <br />S <br />(TT SITE NAME <br />:ILITY ADDRESS <br />F kITYCONTACT N M <br />SITE PHONE Z With AREA CODE <br />U <br />R <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />CITY <br />�� <br />E <br />STATE <br />ZIP CODE <br />t! of TANKS <br />KS <br />at SITE <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I:D. »(s) <br />L <br />I <br />T/BILL[H NAME <br />= S624.00 minimun <br />APPLI NT CONTACT <br />C <br />LINC ES1SS / <br />TANK I.D. l(s) <br />PI <br />A <br />ITANK <br />R <br />APPLICANT PHONE # WITH AREA CODE <br />» TANK(s) X 5234.00 = <br />= S234.00 minimum <br />7 <br />CIT <br />STATE ZIP CODE TYPE of APPLICATION <br />C _ (Closure, Installation, etc.l /a <br />MI <br />TOTAL <br />A <br />ANNUAL FACILITY FEE (Prior <br />to January 1, 1991) 5100.00 <br />C <br />1986 1987 <br />1988 <br />1989 1990 <br />XXXX XXXX <br />S <br />C <br />T <br />I <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX XXXX <br />S <br />V <br />E <br />TANK FEE = 550.00/TANK <br />(Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />F <br />0 Tanks = <br />(multiply x by fee for <br />1986 <br />1987 <br />1988 11989 1990 <br />1991 11992 1993 <br />1995 1996 <br />11994 1 1 <br />A <br />CS <br />each year applicab(e) <br />XXXX <br />XXXX <br />TANK PENALTY FEES ASSESSED <br />I XXXX <br />XXXX <br />I <br />L <br />S <br />I <br />T <br />STATE SURCHARGE = S56.00 <br />each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />Y <br />4 Tanks x S56.00 <br />(Enter amount and year) <br />1988 through 1990 <br />1991 through 1996 <br />S <br />C <br />L <br />PERMANENT CLOSURE (Removal or Authorized Closure-in-Place)I <br />TANK I.D. »(s) <br />0 <br />S <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br />» TANKCs) X 5234.00 = <br />U <br />R <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.O. »(s) <br />E <br />TEMPORARY -CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />S2-34.00 minimum <br />PI <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I:D. »(s) <br />A <br />N <br />PLAN CHECK FEE = S78.00/hour (8 hours minimm/FACILITY) <br />= S624.00 minimun <br />RI <br />El <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. l(s) <br />PI <br />A <br />ITANK <br />R <br />TANK LINING REPAIR FES = 578.00/hour (3 hours minimum/TANK) <br />RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />L <br />» TANK(s) X 5234.00 = <br />= S234.00 minimum <br />PIPING REPAIR FEE 578.00/hour (3 hours minimum/FACILITY) <br />= 3234.00 minimun <br />MI <br />TRANSFER FEE = 520.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />S <br />� <br />� <br />C <br />CONSULTATION FEE = S78.00/hr <br />SAMPLING INSPECTION FEE <br />= S78.00/hr <br />S <br />S <br />S <br />S <br />TOTAL DUE S <br />FOR OFFICE USE ONLY <br />SWEEPS I COMPUTER x I LOC CODE I O(S7Sl1EEPS COMPUTER I LOC 000E RECEIVED RECEIVEDCHECK »/CAS1i I RECEIVED 3Y DATE RECEIVEDCHECK »/CAS}i I RECEIVED 3Y DATE - <br />a <br />EH 23 032 (REVISED 10-28-93) 3 ` <br />4 <br />