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SAN JOIIWIN COUNTY PUBLIC HEALTH SERVICES . ENVIRONMENTAL HEALTH DIVSION <br /> mmERCRCUMD STORAGE TANK PROGRAM - FEE WORKSHEET as 8r <br /> FACILITY;CONTACT NAME <br /> S FACILITY SITE NAME J <br /> I 0S � r <br /> T SITE RHONE. rYitp?fq;.C� <br /> E FACILITY ADDRESS // I �• <br /> & STATE ZIP COQE # of TANKS <br /> CITY / 2i G�q1� '2� at SITE <br /> A 7 / <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> M STA Ell ZIP CODE TYPE of APPLICATION <br /> T CITY (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 XXXx Xxxx <br /> A O ✓ �v <br /> D xxxx xxxx ' S <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I 5170/TANK (After January 1, 1991) <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) <br /> E 0 Tanks 1986 1987 1988 1989 11990 1991 11992 1993 1994 1995 1996 <br /> = <br /> F (multiply # by fee for <br /> A each year applicable) xxxx )=x <br /> I TANK PENALTY FEES ASSESSED XXXX xxxx <br /> L <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> Y # Tanks,1_ x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) O p - c <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-i n-Place) TANK I.D. #(s) /.- --, <br /> L = _ S <br /> # TeNK(s)__�__ X 5234.00 <br /> 0 CLOSURE FEE $78.00/hour (3 hours minimum/TANK) - .+-..: <br /> S -- <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R5 <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimAN FACILITY) 5234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.O. #(S) <br /> L <br /> A = 5624.00 minimum S <br /> M PLAN CHECK FEE - 578.00/hour (8 hours minim m/FACILITY) <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK 1.0. #(s) <br /> E S <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = <br /> A S <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br /> R S <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br /> = 5234.00 minimum <br /> NJ TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 378.00/hr <br /> 3 <br /> I <br /> S = 578.00/hr <br /> C CONSULTATION FEE = f78.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE J. •j <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER LOC I.. I DIST CODE AMOUNT RECEIVED CHECK ;9/CASHRECEIVED BY DATE R�CEfVED <br /> S <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />