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SAN JOAOUI&TT PLBLIC HEALTH SERVICES - ENVIRCIIMENTALISLiH DIVSIOM <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> s 7:7-1' S. LC IST AVE Z4V7 599 6666 <br /> CITYSTATE ZIP CODE # of TANKS <br /> A /OOn/ / `5366 at SITE 2 <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L TFC/.v <br /> I <br /> CMAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A 4l Her rc�f ,s c � 2G9 si y 9653 <br /> T CITY y� STATE ZIP CODE I TYPE of APPLICATION .rFAgj,Y& <br /> /ylooEStO (/� 9SJJ (Closure, Instatlation, 'Etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If App(icable) XX)(X %XXX S <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year appticabte) S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX S <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H b S Code, Section 25287 <br /> T <br /> T At Tanks z $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> O CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) Z X 5234.00 = S S/6� <br /> S <br /> U TEMPORARY CLOSURE (Plan Review b inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 278.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspect i ons) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours mininam/FACTLITY) $624.00 minimum S <br /> v <br /> R REPAIR FEE (Workplan Review 3 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimm/TANK) # TANK(s) X 5234.00 S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 2234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 278.00/hour (3 hours minimum/FACILITY) - $234.00 minimum S <br /> MTRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION - S78.00/hr f <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr <br /> �7 TOTAL DUE S SL6�Q <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED ,3 <br /> - �t✓`r'%� G� 3Z- V 5 Z-c�� 2G � Ci '—/$-Jr.'l 3 <br /> EH 23 032 (REVISED 11-1.92) - Page 11 <br />