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SAN JMOU[N CO <br /> iwTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> UN OUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S ,FACILITY SITE NAME MCODE # <br /> CONTACT NAME <br /> I <br /> T NE # with AREA CODE <br /> E FACILITY ADDRESS <br /> 8 # of TANKSCITY at SITEA <br /> PT CONTACT NAMEP APPLICANT/BILLING NAME <br /> L <br /> I T PHONE # WITH AREA CODEC MAILING ADDRESS <br /> A <br /> MYPE of APPLICATIONT CITY Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 xxxx X%XXXXXX X%%X xxxx 3 XXX%XXx%%%xxx <br /> A <br /> Cxxxx xxxx xxxx I XXXx XXXx 3 Xxx%xxxxXx%%x <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> 1 <br /> V TANK FEE = 350.00/TANK (Prior to January 1,1991) 3170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for 3 <br /> A each year applicable) xxxx %XXX XX%X %X%X XX%x <br /> C g <br /> I TANK PENALTY FEES ASSESSED xxxx XXX% xxxx xxxx xxxx <br /> L <br /> U STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T 1991 through 1996 <br /> Y # Tanks x $ <br /> 56.00 1988 through 1990 <br /> (Enter amount and year) 3 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = 3 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R3 <br /> E TEMPORARY CLOSURE FEE = 878.00/hour (3 hours minimum/FACILITY) $234.00 mininun <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A g <br /> N PLAN CHECK FEE = 378.00/hour (8 hours minimum/FACILITY) = $624.00 minimum <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 378.00/hour (3 hours minimum/TANK) # TANK(s) % 3234.00 = 3 <br /> A3 <br /> I TANK RETROFIT REPAIR FEE = 378.00/hour (3 hours min./FACILITY) = $234.00 minimus <br /> R3 <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 378.00/hr $ <br /> I <br /> S g <br /> C CONSULTATION FEE = 378.00/hr SAMPLING INSPECTION FEE = S78.00/hr <br /> TOTAL DUE 3 <br /> CE USE ONLY ......... .....__...._._....................._...,.............,..,...::::,::,:,::::,::::::::::::::::::::::-:,:::::: ::::::.::,::_:::::::::.—: ::::::::.—:::::::::::::::.::::::::::�::..;... <br /> FOR OFFICE . .. ... ....................._............::::::::.........,..:...._....::.:.:....._.............,..::::::!:!:!:.-:::::::::m <br /> .. .......:::: ..!..._................_. :........ ..... <br /> ........ ........................:::::::.::::.:.:::....... :::::::::::::.::..:..::..::::..:..:.......::::":_:::::::.::..__.... . ..._.._................_............_............:.::.................._:............................... ............ <br /> .0 . . MO ..... . <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> $ <br /> Us <br /> .......................................................................................................................................... :...:.....::...:_....::_�:::::::_�:::::::::::::!!!!!.::!!:a'—n_ :: :......:.._::un <br /> :._. <br /> mimNut <br /> 9 <br />