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NTY <br /> UBLIC <br /> ALTH <br /> SAN JOAEEINUV,ROMENTAIUHEALTHEDIVISIONVICEf <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> FACILITY SITE NAME <br /> F <br /> Hilda Burkhardt Same <br /> I SITE PHONE ! with AREA CODE <br /> FACILITY AOD0.E59 <br /> 1 CITY I. <br /> SLATE ZIP CODE et of <br /> TANKS O <br /> Y <br /> APPLICANT CONTACT NAME <br /> AA APPLICANT/BILLING NAME <br /> P Same as above Same as above <br /> I RAILING ADDRESS <br /> APPLICANT PHONE ! WITH AREA CODE <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> CLOSURE, INSTALLATION, ate. Sample <br /> T <br /> TOTAL <br /> A 1986 1987 1988 1989 1990 <br /> C <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) • $100.00 f <br /> I <br /> V $170/TANK (after January 1, 7991) <br /> E TANK FEE $50.00/TANK (prior to January 1,1991) <br /> F ! Tanks • 1986 1987 1988 1989 1990 1991 1992 1993 T 1994 11995 1996 S <br /> A (auttiply t«VV fee for <br /> C each year UG fee <br /> e) <br /> t <br /> L STATE SURCHARGE $56.00 each TANK tum every 5 years) See California N 6 S Cade, Section 2528 <br /> I 1986 through 1990 1991 through 1996 <br /> 1 ! tanks N $56.00 $ <br /> Y (enter 0- and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. !(s) • $ <br /> C ! TANK(s)_ % !159.00 <br /> L CLOSURE FEE • $53.00 per hour (3 hours minimum per TANK) <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for rev!ew/Inapeetlons) TANK I.D. (s <br /> E TEMPORARY CLOSURE FEE • $150.00 each TANK <br /> ! 7ANK(s) __ K $150.00 • f <br /> P PLAN CHECK (Install. Plan Review i Construction Inspection$) TANK I.D. f(s) <br /> L f <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimm per Facility) • !424.00 mininAsa <br /> TANK I.D. !(a) <br /> R REPAIR FEE (workplan review L construction Inspections) % $159.00 + $ <br /> P 1ANK REPAIR FEE $53.00 per hour (3 hours mfniaum/TANK) ' ! TANK(s) __ <br /> A s <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour mfnlaAm per facility $159-00) <br /> M TRANSFER FEE • 1120.00 UNAUTHORIZED RELEASE EVALUATION • $53.00/hr <br /> f <br /> I = $53.00/hr $ <br /> C ``CONSULTATION FEE • 553.00/hr SAMPLING INSPECTION FEE TOTAL DUE $1 .00 <br /> emer� nrew'mn•matiuur�:���:E�M�t�L��lvtu�r, <br /> ..—$VEEP$� PVlcn <br /> CJ } <br /> O IIIIIIIOIfI@ �p�l�A�l����@�1 OMMPNI@IPIItlPFIP19FMM11MMM�MP <br /> 9i9YiiiP1111®N••m••••_•••••• <br /> EN 23 032 (Revised 4/8/91) <br /> Page 11 <br />