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SAN " JIM COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> S FACILITY SITE NAME !7dkOUMD STORAGE TANK PROGRAM - FEE WORKSHEET <br /> T l/YG FACILITY CONTACT NAME <br /> T <br /> E FACILITY DRE S <br /> R SITE PHONE # with AREA CODE <br /> CITY <br /> A STATE ZIP CODE <br /> P # of TANKS <br /> P APPLICANT/BILLING NAME at SITE <br /> L <br /> 1 APPLICANT CONTACT NAME <br /> C MAILING ADDRESS <br /> A <br /> N APPLICANT PHONE # WITH AREA COOE <br /> T CITY <br /> STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> A TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 1986 1987 1988 1989 1990 <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicab(e) XXXX XXXX S <br /> 1 XXXX xxxx <br /> # Tanks <br /> V TANK FEE _ 150.00/TANK f <br /> E (Prior to January 1,1991) <br /> 5170/TANK (After January 1, 1991) <br /> = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (iniil ti PlY # by fee for <br /> A each year applicab(e) %%%% xxxx <br /> C <br /> I TANK PENALTY FEES ASSESSED <br /> L %x%% XXXX <br /> I STATE SURCHARGE = 556.00 each TANK $ <br /> T (Due every 5 years) See California N f S Cade, Section 25287 <br /> Y # Tanks z 156.00 <br /> (Enter amount and 1988 through 1990 <br /> year) 1991 through 1996 <br /> 199 0 1995 <br /> S l z .b0 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in- <br /> L Place) TANK I.D. #(s) <br /> 0 CLOSURE FEE _ !78.00/hour 0 hours miniMum/TANK) <br /> S # TANK(s) t X $234.00 = <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) $ rX 3 T•� <br /> R TANK I.D. #(s) <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) <br /> # TANK(s) X !234.00 = <br /> f <br /> P INSTALLATION PLAN CHECK (Plan Review $ Construction <br /> L Inspections) TANK I.D. #(s) <br /> A <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) _ <br /> - $624,00 minimum $ <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) <br /> E TANK 1-0. #(s) <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /> A # TANK(s) _ X 2234.00 = f <br /> um <br /> R <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) $234.00 minim= f <br /> PIPING REPAIR FEE = !78.00/hour (3 hours minimum/FACILITT) <br /> _ $234.00 minimus 5 <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br /> I <br /> S f <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE <br /> = 578.00/hr f <br /> FOR OFFICE USE ONLY TOTAL DLJE f <br /> E7*R* !-:a' ...... <br /> SWEEPS # ...................................................................................:-:!::::::::_�::::::::e::�::�_:::::�:::::::�?!r-'---."":"r-:-'.-..._..._................ <br /> CONFUTER # LOC .--::-:.—::,::-.-:.._:::......... _...... <br /> CCOE DISI .. .........._ :::::::::::::: i (i` i :t: :::::!::: :::F;:::::.:::_ _.... -... <br /> CODE AMOUNT RECEIVED CHECK #/GSH RECEIVED BY f� <br /> ....................... .. <br /> DATE RECEIVED <br /> .................................:::::::::::::::::::::::_::::s::-: :::-:::::.-:�:-ee!::e ._..._.::^:-::t.=.:::s <br /> EH 23 032 (REVISED 6-21-93) ......................_...._,:!:::!:..... <br /> :::,,:�::::::::a <br /> Page 11 <br /> • <br />