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'- SAN JOAGUINPUBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVSION <br /> U RGROUIID STORAGE TANK PROGRAM - FEE WORKSHEE <br /> Sj FACILITY SITE NAME FACILITY CONTACT NAME <br /> T SITE PHONE # with AREA CODE <br /> E FACILITY ADDRESS <br /> CITY STATE ZIP CODE # of TANKS <br /> A C# �—°3 at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> C MAILING ADDRESS PPLICANT PHONE # WITH AREA CODE <br /> T CITY �S� <br /> ZIP CODE TYPE of APP <br /> ► lV(�T f27 �'r 4'S�f� (Closer Installation etc.) <br /> TOTAL <br /> 1986 1987 1 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX xxxx s <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xM xxn 5 <br /> 1 <br /> Y TANK FEE $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E r7 <br /> # Tanks lC,� 1986 ]987 ]988 1989 1990 1991 1992 1943 1944 1995 1996 W1► C7g_3 G49 <br /> F (multiply # by fee for I 5 — '1C[� dei <br /> A each year applicable) xxxx XX)C( <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx 5 <br /> L <br /> 11 STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1988 through 1990 1991 through 199b (jwd d 5� <br /> (Enter amount and year) <br /> IqctS' S 1 12 `' <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK E.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = f <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(S) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum 5 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) ju <br /> L <br /> A C j `tCJ <br /> N PLAN CHECK FEE = S78.00/licur (8 hours minimum/FACILITY) = $624.00 minimum s I <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P1 TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <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 S <br /> N TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr 5 <br /> TOTAL DUE $IC) d� <br /> FOR OFFICE USE ONLY — -- <br /> = SWEEPS # - COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY OATS RECEIVED _ <br /> EH 23 032 (REVISED 10-28-93) <br />