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SAN JOAWINA&TY PUBLIC HEALTH SERVICES - ENVIRONMENTALMLTH DIVISION U ROUND STORAGE TANK PROGRAM - FEE WORKSNE S FACILITY SITE NAME FACILITY CONTACT NAME 1 -z :cam L wl T E FACILITY ADDRESS SITE PHONE # with AREA CODE b Z Scao L.4', 1 zoq - — zq TOTAL DUE X%XX %XXX %%X% XXXX A CITY/ W STATE ZIP CODE �S ZL(p # of TANKS at SITE '3 P E C P APPLICANT/BILLING NAME AP LI CANT CONTACT NAME w. ELCa I T FACILITY PENALTY FEES ASSESSED (If Applicable) C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE A 2� e �� T o — zz- zH i8_ N T CITY ^ STATE ZIP CODE TYPE of APPLICATION , Pte„ O MEN Cd 9( 7 (Closure, Installation, etc.) TOTAL C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) 1986 1987 1988 1989 1990 ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = S S TOTAL DUE X%XX %XXX %%X% XXXX X%XX S %XX%XXXX%%%XX A TANK I.D. #(s) R E C $234.00 minimum S T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX %XXX XXXX XXXX XXXX $ XXXXXXXXXXXXX I V TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) E # Tanks= _ 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 F (multiply # by fee for %XXX XXXX XXXX XXXX XXXX S A each year applicable) C I TANK PENALTY FEES ASSESSED X%X% XXXX X%X% XXXX XXXX $ L 1 STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 T Y # Tanks x 556.00 1988 through 1990 1991 through 1996 (Enter amount and year) E C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. #(s) L E S A 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = S S TOTAL DUE E U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum S P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) L E S A P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S R REPAIR FEE (workp(an Review 8 Construction Inspections) TANK I.D. #(s) E E S P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S A TOTAL DUE E I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S R PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S M TRANSFER FEE = $20.00 1 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr E S C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr S TOTAL DUE E SWEEPS 4 1 COMPUTER 9 1 LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK #/CASH I RECE