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• SAN JOAM IN Cr R PUBLIC HEALTH SERVICES - ENVIRONMENTAL HES DIVSION <br /> U,,� STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T sor-,o01 CA <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> s - O <br /> CITY STATE ZIP CODE # of TANKS <br /> A _ I� at SITE <br /> P �C\ <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N o�O — <br /> T CITY LTATEI ZIP CDDE TYPE of APPLICATION <br /> 5 l _ h& (Closure, Installation, etc.) Q � <br /> �O 1olaq7 TOTAL <br /> 1986 1987 1988 1989 I 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A )0= =O( )O= I XXXX mask I S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I X)= I X)00( mack I xxxx xxxx S xxxxXxxx <br /> 1 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) I 5170/TANK (After laniary 1, 1991) <br /> E <br /> # Tanks = 1987 i 1988 1989 11990 1991 11992 ( 1993 1994 1995 1996 11997 <br /> F (multiply #-0y fee for <br /> A each year applicablU XXXX I XXX% xxxx I =cx )0= I I I I S <br /> C- <br /> I TANK PENALTY FEES ASSESSED I xxxx ( xxxx xxxx X)= IX)= I I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = 518.50 Is <br /> T <br /> Y # Tanks x 58.00 1988 through 1990 (S56) 1991 through 1996 (356)T1997 <br /> SURCHARGE i-0R 1997 XXXXXXXXXXXXXXXXXXXXX)=XXX XXXXXXXXXXX)=XXXXXXXXX S <br /> Cl PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> 0 CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = 5 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> iI INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum5 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.O. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 378.00/hour (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) = 5234.00 minimum I S <br /> R <br /> PIPING REPAIR FEE = 578.001hour (3 hours minimum/FACILITY) 5234.00 minimum s <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION - 578.00/hr I I I S <br /> C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr I I S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER S I LOC CODE DIST CODE I AMOUNT RECEIVED I CHECK #/CASH RECEIVED BY ' DATE RECEIVED <br /> EH 23 032 (REVISED 5-27-97) <br />