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SAN JU40UIN COUKTY PUBLIC HEALTH SERVICES - ENVIRWIEKTAL HE)RTH OIVSION <br />UIDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAME <br />ANNUAL FACILITY FEE (Prior to January i, 1991) = $100.00 <br />FACILITY CONT CT HANE <br />T <br />C <br />T <br />I <br />_ <br />0.) <br />L71� <br />E <br />FA LITY ADDRESS <br />- <br />_ E Ppx E �i th AREA CODE <br />—%t�.� <br />P Tanks <br />(multiply fee for <br />each year app icable) <br />1 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br />1% <br />& <br />TANK PENALTY FEES ASSESSED <br />XXXx XXXX 7000( S <br />I <br />T <br />CITY <br />E OWE <br />A <br />` <br />��U � at SITANKS <br />P <br />P <br />APP ICANT/BILLING NAME <br />APPLICANT TACT NAME <br />L <br />— N <br />nJv <br />nil S <br />C <br />MAILING ADDRESS <br />U <br />R <br />PPLICANT PHONE M WITH AREA CODE <br />AUy�l <br />L <br />Sve <br />— <br />x <br />T <br />ClFY. �' <br />W Imo- '(.. <br />A <br />N <br />E <br />t''� <br />P C00 PLICATION <br />yS (p (Closure, nstallation, etc.) <br />TOTAL <br />A <br />ANNUAL FACILITY FEE (Prior to January i, 1991) = $100.00 <br />1986 1987 1988 1989 1990 <br />X7001 XXXX XXXX S <br />C <br />T <br />I <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />xxxX X700( xxxx S <br />V <br />E <br />TANK FEE - 550.00/TANK (Prior to Jannry 1,1991) S1701TANK (After January 1, 1991) <br />F <br />A <br />C <br />P Tanks <br />(multiply fee for <br />each year app icable) <br />1 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br />)G= )G= =a S <br />I <br />L <br />TANK PENALTY FEES ASSESSED <br />XXXx XXXX 7000( S <br />I <br />T <br />STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California N & S Code, Section 25287 <br />T <br />/ Tanks x $56.00 <br />(Enter anaurt and year) <br />1966 through 1990 1991 through 1996 <br />S <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. M(s) I2- <br />0 S <br />CLOSURE FEE = 578.00/hour (3 hours minimAVTANK) i TANK(s) i X 5234.00 = S '7O <br />U <br />R <br />TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. !(s) <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 boos minimum/FACILITY) 5234.00 minimus 5 <br />P <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. A'(s) <br />A <br />N <br />PLAN CHECK FEE - 578.00/hour (8 hours minium/FACILITY) = $624.00 minimum <br />S <br />R <br />E <br />REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. i(s) <br />P <br />A <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) M TANK(s) X $234.00 = <br />S <br />I <br />R <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br />S <br />PIPING REPAIR FEE = 578.00/hour (3 hours ninimum/FACILITY) = 5234.00 minimum <br />5 <br />N <br />1 <br />TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />5 <br />S <br />C ICONSULTATION <br />FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br />s <br />TOTAL DUE <br />5 Q <br />EH 23 032 (REVISED 4-29-94) Page 11 <br />