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SAM JOAOUtM COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSICM <br /> UNOERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SIFACILI Y SITE NAME I FACILITY CONTACT NAME <br /> I <br /> T L <br /> 3 fAClll Y ADDRESS,,, (� / SITE t� X with AREA CODE � I <br /> CITY STATE ZIP CODE 9 of TANNKK^S {,1LCln <br /> A <br /> P at SITE <br /> P APPLICANT/BILLING NAME APPLI C,.INT CONTACT NAME <br /> L /s4' <br /> I <br /> C MAILING ADDRESS <br /> A APPLICANT 1"'Nl H AREA CODE <br /> TI CITY STATS 21P CODE TY of APPL(Gi[ON —t'pQ,d,/ L9t-K� <br /> C (0171 q. (Cl osu , Installation, ete. / <br /> TOTAL <br /> 1986 1987 11988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 7 <br /> C XXXX XXXX I /�0 I /�0 $a00 <br /> T11 FACILITY PENALTY FEES ASSESSED If Applicable) XXXX x:= I `I 5Lao Q <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 9 Tanks = 1986 1987 11988 11989 1 1990 1991 11992 1993 11994 1995 11996 <br /> F (multiply 9 oy fee for <br /> 'l n <br /> A each year apolicable) XXxX XXXX <br /> C 50 150I/w 11 lJl /?O� S/- <br /> ' Q LL77 l/ <br /> LI TANK PENALTY FEES ASSESSED XXxx XXXX 156 <br /> 156 <br /> S Il In 1110 11 <br /> -76 1 <br /> S <br /> [I STATE SURCHARGE = 556.00 each TANK (Due _ ery 5 years) See California H 3 S Code, Section 25247 <br /> T9 Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amounc and year) <br /> CI PERMANENT CLOSURE (RemcvaL or Authorized Closure-in-Place) I TANK 1_0. 9(s) <br /> L <br /> OI CLOSURE FEE - 578.00/hour (3 hours minim,MTANK) 4 TANK(s)_ X $234.00 = S <br /> S <br /> UTEMPORARY CLOSURE (Plan Review 3 (nspecti ons) TANK I.D. 9(s) <br /> R <br /> E TEMPORARY CLOSURE FEE • 578.001hour (3 hours minimum/FACILITY) I 5234.00 minimm 5 <br /> P1 INSTALLATION PLAN CHECK (Plan Review 6 Construction Inspections) TANK I.D. 9(s) <br /> Ll <br /> A <br /> NI PLAN CHECK FEE = 578.00/hour (8 hours zinimrVFACILITY) $624.00 minimm S <br /> RI REPAIR FEE (Workplan Review 3 Construction Inspections) I TANK 1_0. 9(s) <br /> E, <br /> P TANK LINING REPAIR FEE = 578.001hour (3 hours minimm/TANK) 9 'ANK(s) X 5234.00 = S <br /> A <br /> 11 TANK RETROFIT REPAIR FEE - 578.00/hour 13 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = 5234.00 mini mm S <br /> NI TRANSFER FEE. = 520.00 UNAUTHORIZED RELEASE EVALUATION - 578.00/hr S <br /> Cl CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE - 578.00/hr 5 -y , <br /> TOTAL DUE 3 <br /> FOR OFFICE USE ONLY <br /> WEEPS 9 I COMPUTER ,OC CODE )(ST CODE I AMCUNT RECEIVED CHECK 9/GSH RECEIVED 3Y, )ATE RECEIVED <br /> I O / Id00 � I S I I <br /> EH 23 032 (REVISED 10-29-93) �, <br />