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SAN JOAaIJl)i PUBLIC HEALTH SERVICES - ENVIRONMENTAL # DIVSIOU <br /> R= <br /> STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I y rs 4-vr 1j le cle 5 tr,1 c- <br /> T SITE PHONE # with AREA CODE <br /> E FACILITY ADDRESS <br /> & # of TANKS <br /> CITY STATE ZIP CODE <br /> t SITE ;2— <br /> A A $,� cl�c <br /> P 'ONTACT NAME <br /> P APPLICANT/BILLING NAME + <br /> I +� ONE # WITH AREA CARE - <br /> C MAILING ADDRESS l j <br /> A �. 0 , l3vx —73YS — <br /> N `f APPLICATIO Q'c' a Pf- v <br /> T CITY /�f"iCJ *e, lnstaklat`on, etc.) <br /> l� 1 TOTAL <br /> r� 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 311--,�► `' 3 <br /> A 1©[: !Dc's /c70 L7 /bc`� SOc� <br /> C xxxx xxxx <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) /0 0 /d n 3 3 d <br /> I $170/TANK (After January 1, 1991) <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) <br /> E <br /> # Tanks �— 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 199b <br /> F (multiply # by fee for <br /> A. each year applicable) /cc /p0 /C20 /0© /00 -?,qC) D 0 <br /> 3 13 � <br /> j ! TANK PENALTY FEES ASSESSED xxxx Xxxx /rjb /C#Q /0d 31'L 3Y0 <br /> E(Enter <br /> i RGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> =199:1 through 1996 <br /> x 556.00 1986 through 1990 <br /> nt and year) ;c( µ,'r C�vsw�Qp��N� S <br /> r/a <br /> C PERMANENT CLOSURE (Removal or Authorized Glosure-in-Place) TANK I.D. #(s} <br /> L # TANK(s) X 5234.00 = S <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /> S TANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R X $234.00 = 5 <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A = S624.00 minimus 5 <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) <br /> RtRE?AIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E 3 <br /> PLINING REPAIRFEE = 378.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00AIRETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum <br /> R = S234.00 minimum 3 <br /> PIPING REPAIR FEE = 378.00/hour (3 hours minimEm/FACILITY) <br /> M` TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 378.00/hr <br /> 3 <br /> SI <br /> S = $78.00/hr S <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE $ 3 75 c1 C) <br /> FOR OFFICE USE ONLYMEMO <br /> ilianER s=ss::;.:.:;..............•.::-'_::::. <br /> � # LOC CODE DIST CODE AMOUNT RECEIVED <br /> SWEEPS 9 COMPUTER #/CASH RECEIVED BY DATE RECEIVED <br /> a <br /> _- <br /> -- <br /> RC7 – <br /> DIE' � _.__.' ..__..._..... :.. <br /> =: T 3 <br /> Page 11 <br /> EH 23 032 (REVISES <br />