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fi SAN JOACUIY , PUB`LIC HEALTH SERVICES ENVIRONMENTAL HEA IVSION <br /> CURD STORAGE TANK PROGRAM - FEE UORKSHEET W <br /> S FACILITY SITE NAME '`C A # _ I � FACILITY CONTACT NAME <br /> E FACILITY ADDRESS SITE PHONE X with AREA CODE <br /> & -ice MAfti1 ST, 209 - 1R9 . 2-3/3 <br /> A CITY � STATEZ � b� at SI TENKS <br /> P I� <br /> P APPLICANT/BILLING NAME /�C�•,�,�. APPLICANT CONTACT NAMM�E� p,� <br /> If'1J..Jly--. .S `-'r-fiTT�G� <br /> A MAIL(NI 3ADDRESS�: M� ��� APPLICANT PHONE X WITH AREA CODE <br /> N 17 70 17 Gi • I"-Z) <br /> T CITY SZATE ZIP CODETYPE of APPLICATION <br /> Fff FPtl•-d 14A (::Pr 94454 (Closure, Installation, etc.) CWSJPZE <br /> TOTAL <br /> 1 1 <br /> ANNUAL FACILITY FEE (Prior To January 1, 7991) = $100.00 1986 1987 1988 1989 1990 <br /> A XXXX XXXX XXXXXXXX S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (if Ax(icable) I xxxx XXXX xxxx XXXX S <br /> I <br /> V TANK FEE 550.00/TANK (Prior :o January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> Tanks = 7986 ! 1987 11988 1989 1990 7991 17992 11993 11994 17995 11996 �V �daa1 <br /> F (multiply : by fee for <br /> A each year applicable) I xxxx xxxx I xxxx xxxx I I 5 ^ <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX xxxx XXXX I xxxx I I S <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T n <br /> Y Tanks x 556.00 1988 through 1990 1991 through 1996 ) Qom, I <br /> (Enter amount and year) <br /> 1995 S 224 <br /> LI PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s)— 112107- vaa,oll <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) x TANK(s)_ X 5234.00 = S �1✓�0•$'_ <br /> 5 <br /> U TEMPORARY CLOSURE (Plan Review & inspections) I TANK I.D. :(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> LINSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. :(S) <br /> A 00 O <br /> N PLAN CHECK FEE = 378.00/hour (8 hours minimum/FACILITY) 5624.00 minimum S 2.1-' <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. X(S) <br /> E <br /> P TANK LINING REPAIR FEE = 878.00/hour (3 hours minimun/TANK) TANK(s) X 5234.00 = 5 <br /> A <br /> 1 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimus s <br /> M TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr I $ <br /> TOTAL DUE $2,464.1^0 <br /> FOR OFFICE USE ONLY ._rT�. <br /> SWEEPS X COMPUTER LOC CODE DIST CODE AMOUNT RECEIVED I CHECK R/CASH RECEIVED BY I DATE RECEIVED <br /> I 5 A Y <br /> 1f�SED 4-6-95)_._.__.._._ • <br />