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SAM JOIOUIM COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSIOM <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILM CONTACT DAME <br /> If I / OL tL2 <br /> E FACILITY ADDRESS SITE PHONE # with REA CODE <br /> a -? `�� 73 / — 6J <br /> CITY STATE ZIP CODE # of TANKS / <br /> A f '') - at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLILUANT CONTACT NAME <br /> L <br /> I 55 <br /> C NAILING ADDRESS APPLICANT PHONE # NIT AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APP ICATION <br /> (Closure, tallation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 1100.00 p� �z,ff <br /> � X%XX � V � 1- Jo <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX t <br /> 1 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (Af a J 8/111ry 1, 1) <br /> E <br /> 9 Tanks = 1986 1987 1988 1989 1 1990 1991 1992 1 199 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX I XXXX O15015 O 17c) rX f <br /> C <br /> ITANK PENALTY FEES ASSESSED XXXX XXXX S <br /> L 47 <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See Callrnia JiKSsade, Section 25287 <br /> T <br /> T # Tanks ■ 556.00 1988 through 1990 1 through 1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closur -in-P e) TANK I . #(s) <br /> L <br /> 0 CLOSURE FEE - f78.00/hour (3 hours inim a/TA K # TANK(s)_L_ X 1234.00 - f L <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 t pert ons I TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/h (3 ours imm/TANK) # TANK(s)_ X $234.00 - S <br /> P INSTALLATION PLAN CHECK (Plan Re iewl Con#(iruction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> M PLAN CHECK FEE - 178.00/hour (8 hours nimuVFACILITY) = 1624.00 minimum S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 178.00/h0er (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 1234.00 minimum f <br /> R <br /> PIPING REPAIR FEE = 178.00/hover (3 hours minimum/FACILITY) = $234.00 minimum f <br /> M TRANSFER FEE = 120.00 / UNAUTHORIZED RELEASE EVALUATION = $78.00/hr f <br /> I <br /> S <br /> —CONSULTATION FEE _ .00/hr SAMPLING INSPECTION FEE - 178.00/hr f <br /> TOTAL DUE f <br /> FOR OFFICE USE ONLY .T m_ <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> ��0 1 <br /> ,ee>va nnn ter' ' <br /> ss <br /> EH <br /> �xul <br /> EH 23 032 (REVISED 6-21-93) ti Page 11 v... <br />