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SAI JOAQUIN C T PUBLIC HEALTH SERVICES - ENVIRONMENTAL I 'H DIVSION <br /> UNDCRGROUND STORAGE TANK PROGRAM - FEE WCRKSHEE, <br /> ACILITY SITE NAME FACILITY CONTACT NAME <br /> Sc -- i4 J�cx K,tJt ric <br /> c FACILITY ADDRESS 5�E PHON # 'th AREA CODE <br /> s 1 Y 6Ja. 2h �l <br /> -1 - 17 Cl_ <br /> CITY I <br /> NEI ZIP`` CODE # of TANKS -Y To (3u <br /> P " ' + J� at SI7E <br /> Kmfj <br /> P APPLICANT/BILLING NAME APPLICANT CONTn NAME <br /> 1 't` L l r TZ7 n� Sk0 <br /> C HAILING ADDRESS PLICANT PHONE # WITH AREA CODE <br /> N s �)�1 c s1,j3Ia� <br /> T CITY STATE ZIP CODE TYPE of APPLI <br /> N �' ��1 t^✓}- 9yS'Yt� (Closure ic nstallat , etc.) <br /> TOTAL <br /> 1 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 986 1987 1988 [19-8-9-F-1990 <br /> A XXXX <br /> C XXXX <br /> f <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX %XXX f <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to Jaruary 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 9 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXX% )OW f "� <br /> C <br /> ITANK PENALTY FEES ASSESSED XXXX %)(X)( f <br /> L <br /> 1 STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> T # Tanks ?— x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> jQ.q j f f Z ed <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-P(ace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = S D}. <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(S) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A °31044{ C, <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimm/FACILITY) = S624.00 minimum S Z T <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) I TANK I.D. #(s) <br /> Ei <br /> P TANK LINING REPAIR FEE = S78.00/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 S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S f <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr f <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> SWEEPS # I COMPUTER # LOC CODE DIST CODE I AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> S = <br /> EH 23 032 (REVISED 10-28-93) <br />