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SAN JOAQUIM WAh PUBLIC HEALTH SERVICES - ENVIROMWNTAL Wdb DIVSION
<br /> UNBEIROUND STORAGE TANK PROGRAM - FEE UDRKSHEE
<br /> Y
<br /> S FACILITY SITE NAME P1 p FACILITY CONTACT HANE
<br /> 1 IAO -fir G G �C
<br /> T
<br /> E FACILITY ADDRESS SITE PHONE N with AREA CODE
<br /> A L � �Co
<br /> CITY 1 II� STA�Tn(pp �Z P CODE N of TANKS
<br /> A / 1 /
<br /> P
<br /> P APPLICANT/BILLING NA EII U APPLICANT CONTACT NAME
<br /> , I
<br /> C RES
<br /> MAILING AOOS L `r 3 5_. APPLICANt PHONE N NRH AREA ME
<br /> 9-
<br /> T
<br /> T CITY -� , STATE ZIP CODE _ TYPE of APPLICATION
<br /> ?7q/S (Closure, Installation, etc.)
<br /> TOTAL
<br /> 1986 1987 1988 1989 1990
<br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00
<br /> A KKKK KKKK j()C)p3 f U()
<br /> C
<br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) KKKK xxxx 1 $ Op OO
<br /> I
<br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991)
<br /> E
<br /> # Tanks = v2 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996
<br /> F (multiply # by feefor
<br /> A each year applicable) KKKK KKKK /(/�? �� $ rpp, 00
<br /> C
<br /> I TANK PENALTY FEES ASSESSED KKKK KKKK 00,00
<br /> L
<br /> 1 STATE SURCHARGE - 556.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287
<br /> 7
<br /> Y # Tanks x $56.00 1988 through 1990 1991 through 1996
<br /> (Enter amount and year)
<br /> 00
<br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(a)
<br /> L
<br /> 0 CLOSURE FEE - 578.00/hour (3 hours minim!zn/TANK) N TANK(s) K $234.00 = $
<br /> S
<br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. N(a)
<br /> R
<br /> F 1FW(` kR1 C.l(YA(1RF. FEF = 1',w,IMhpa1K ) APAH'R AiinilAFNijANC) N jANK.fA) Ia3�:00
<br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s)
<br /> L
<br /> A
<br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimm/FACILITY) _ $624.00 minimus $
<br /> R REPAIR FEE (workplan Review 8 Construction Inspections) TANK I.D. #(s)
<br /> E
<br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimzn/TANK) If TANK(s) K $234.00 $
<br /> A
<br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum S
<br /> R
<br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum
<br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION - 578.00/hr $
<br /> I
<br /> S
<br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr
<br /> TOTAL DUE
<br /> FOR OFFICE USE ONLY
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<br /> FF-
<br /> 4.!
<br /> SWEEPS # COMPUTER N LOC CODE DI Si CODE AMWNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED
<br /> a
<br /> 0
<br /> 1 (� �
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<br /> EH 23 032 (REVISED 6-21-93) • Page 11 0
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