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SAM JOAOUIN COUwTT PUBLIC HEALTH SERVICES - ENVIROIOENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE <br /> WORKSHEET <br /> j r FACILJ T ITE NAME ENV Wiii CON <br /> r R4T SERVICE <br /> E F ( I <br /> T ADDRESS �I�A <br /> 9 - 5 ' S C( 9 ll! 28 Oi rIT' Jb CO"' <br /> CITY STATE ZIP COO! R oIf1 TAjNCKS <br /> A U"I q�j at SITE <br /> P <br /> P APPLICANT/BILLING NAPE APPLICANT CONTACT NAM! <br /> L <br /> CLIMORES! AMLICANT PNM 0 VITN AREA COGS S7ATt ZIP ewe TYPE of APPLICATION <br /> (Cloture, Instal Uacion, etc.) <br /> TOTAL <br /> 1966 1987 1966 19" 1990 <br /> ANNUAL FACILITY FEE (Prior to Jan ary 1, 1991) • $100.00 <br /> A 3 <br /> C <br /> I FACILITY PENALTY FEES ASSESSED (If Applleab(e) R)00( XX)(X S <br /> I <br /> V TANX FEE • 350.00/TANK (Prior to January 1,1991) 3170/TANK (After January 1, 1991) <br /> E <br /> I Tsnks • 1966 1967 1988 1909 1990 1991 1992 1993 1994 1995 1996 <br /> F (mttiply f fee for <br /> A oath year app Lieab(e) <br /> C <br /> I TANK PENALTY FEES ASSESSED )OO(K XXX)( S <br /> L <br /> I STATE SURCHARGE • $56.00 each TANK (Due every S years) Sae California H L S Code, Section 25267 <br /> i <br /> T A Tank$ A $56.00 1966 through 1990 1991 through 1996 <br /> (Enter aauhnt end year) <br /> f <br /> C PERFUNENT CLOSURE (Re vsl or Authorized Closure-In-Place) TANK I.D. f(a) <br /> L <br /> 0 CLOSURE FEE • 378.00/hour (3 hours alninjo/TANK) R TAMK(a)_ X S23A.D0 3 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review S Inspecticro) TANK I.D. f(s) <br /> R <br /> E TEMPORARY CLOSURE FEE • 578.00/hour (3 hors ainlmAA/FACILITT) • SZSA.DO minima S <br /> P INSTALLATION PLAN CHECK (Plan Review S Construction inspections) TANK I.D. f(s) <br /> L <br /> A <br /> N PLAN CHECK FEE • 578.00/ho r (8 hums ain1mum/FACILITY) • S624.00 minimum f <br /> R REPAIR FEE (Workplan Review L Construction Inspections) TANK I.D. f(s) <br /> IF <br /> P TANK LINING REPAIR FEE • 378.00/hour (3 hours a1ninintTARK) f TANK(s) X 9234.00 • S <br /> A <br /> I TANK RETROFIT REPAIR FEE a 578.00/hour (3 hours ain./FACILITY) • 3234.00 mini" 9 <br /> R <br /> PIPING REPAIR FEE • M.00/hour (3 hours minimum/FACILITY) • 9234.00 minis 9 <br /> CI6RM TRANSFER FEE a 920.00 UNAUTHORIZED RELEASE EVALUATION a 978.00/hr 3 <br /> 1 <br /> S <br /> C CONSULTATION FEE • 378.00/hr SAMPLINO INSPECTION FEE • 578.00/hr t <br /> u P* ,� LCsj W11 in ('e r-"G P GZJ a, u. , TOTAL DU,E . t C r U <br /> (1k�R QTY t USE��f" a�,r �dvn� ih 1�zcew 6/�r <br /> WWI"� w3eMa�ccsccccosc.�cccsccoccca oo�c}_A fie[ 77: <br /> llSf•T� li f U: Ull:[il[ N1lA /W�a �C tL s �Ait XG�GIV[U �+ <br /> ---� -- <br /> ,asp•.aaa•r•��waess•homes•wsswraasaeahi•sns�enFasae�aFr.•as•a�•��iaw�isiawssw>•��••s�si• <br /> EN 23 032 (REVISED 3-1-931 Paw 11 <br />