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SAN JOADUIM CCUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHE <br /> y' <br /> Y- SITE NAME <br /> FACILITY CONTACT NAME <br /> rr <br /> ACUITY ADDRESS' <br /> ;_ SITE PHONEI# with AREA CODE <br /> CITY <br /> A STATE ZIP CODE # of TANKS <br /> P Tc:.G' I 1v7) /7 <br /> P APPLICANT/BILLING NAME et SITE <br /> L A I APPLICANT CONTACT NAME <br /> C -MAILIji ADDRESS _ <br /> ' 4 A _ _ APPLICANT PHONE # WITH AREA CODE <br /> T LI7Y - <br /> rl STATE 2IP CODE TYPE of APPLICATION <br /> .(Closure, Installation, etc.) <br /> TOTAL <br /> ' NNUAC'FACILITY PEE (Prior to January 1, 7991) $100.00 1986 1987 1988 1989 1990 <br /> A _ <br /> C <br /> T FACILITY.P-E'RALTY IFEES"ASSESSED-(If Applicable) S <br /> .I <br /> xxxx xxxx i <br /> V TANK FEE = S50:00/TANK <br /> -E ` (Prior to January 1,1991) 5170/TANK <br /> (After January 1, 1991) <br /> Tanks • 1986 1987 1988 19891990 1991 <br /> `F (mu(tiply N byby fee for 1992 1993 7994 1995 7996 <br /> A each year app Cicable) <br /> C <br /> I TANK PENALTY FEES ASSESSED x%%% XXX% s <br /> L <br /> I STATE SURCHARGE _" S5S.00 each TANK (Due ever 5 S <br /> T y Years) See California H & 5 Code, <br /> T # TanksSection 25287 <br /> ,'x 556.00 <br /> (Enter,amountand ear - 1986 through 1990 <br /> Y ) 1991 through 1996 <br /> CPERMAHENTCLO <br /> C SURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> 17 --CLOSURE FEI "= 578.00/hour (3 hours mini —— <br /> 'S aK+a/TANK) # TANK(s)_— X $234.00 = <br /> •U TEMPORAI(Y-CLOSURE (Plan'ReVlew &Inspections) 1 <br /> R TANK I.D. #(s) 1 <br /> -E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimm/TANK) # TANK(s) <br /> X 1234.00 <br /> L <br /> -P -INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> A <br /> N PIAN.CHEC"_EE_=_278.00/hour-(8-hours minimlm/FACII ITY) <br /> = 5624.00 miniaa 5 <br /> R REPAIR FEE (Vorkptan Review & Construction Inspections) <br /> .E � TA I.D. #(s) <br /> P TANK LINING REPAIR FEE - S78.00/hour (3 hours minimun/TANK) # TANK(s) <br /> A __ X $234.00 = <br /> I ,TANK`RETROFIT-REPAIR FEE =578.00/hour (3 hours min./FACILITY) $234.00 mi ninnm 5 <br /> R - <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) 5 <br /> 5234.00 minimm <br /> 1 <br /> TRANSFER FEE = $20.00 <br /> 1 UNAUTHORIZED RELEASE EVALUATION 578.00/hr <br /> S <br /> CONSULTATIDN'FEE = 578.00/hr <br /> SAMPLING INSPECTION FEE = 578.00/hr <br /> S <br /> Xt OFFICE 115E ONLT TOTAL DUE 5 <br /> SWEEPS # LOC CCOE DIST CODE AMOl1NT RECEIVED CHECK �CASH �- ' „- - <br /> RECEIVED BY 3� DATE RECEIVED s a 5 - <br /> 3 <br /> iiz <br /> 23 032 (REVISED 11-1-92) iin �� - `�"iIN <br /> - "- <br /> . . � Page 11 <br />