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SAM JOAQUIN COU LIC HEALTH SERVICES - ENVIRONMENTAL NEA IVSION <br /> UND134FOUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> /FACILITY SITE NAME _ FACILITY CONTACT NAME <br /> !M-P�L <br /> FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 5 yl k G <br /> CITY STATE ZIP CODE # of TANKS <br /> A C k 4at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESSR/� qq APPLICANT PHONE # WITH AREA CODE <br /> AG� <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> PA, dA-t Ale V <br /> s o (Closure, Installation, etc.) <br /> TOTAL <br /> ANNUAL /FACILITY FEE (Prior to January 1, 1991) = 5100.00 1986 1987 1 1988 11989 11990 <br /> A 5 <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If App(icable) XXXX XXXX I E <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 11 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 11993 1994 11995 1996 <br /> F (muLtiply *-Ey fee for <br /> C each year app(icable) I'O 5 ''� <br /> I TANK PENALTY FEES ASSESSED XXxx XXXX <br /> oc <br /> L � � l�� 5 /70, 0 <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H 8 5 Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> E <br /> C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) I TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(&) X 5234.00 = 5 <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/TANK) # TANK(s) X 5234.00 = 5 <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimun/FACILITY) = $624.00 minimum S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = 5 3 7� D <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum E <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours miniauVFACILITY) = 5234.00 mini mm 5 <br /> M TRANSFER FEE = 520.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I S <br /> t <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr I E <br /> Z <br /> TOTAL DUE E T i J 7�i <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE I DIST CODE AMOUNT RECEIVED I CHECK #/CASH RECEIVED BY I DATEto <br /> Rf�CbIV <br /> 'Y S OU <br /> 3 3 <br /> EH 23 032 (REVISED 11-1-92) Page 11 • <br />