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`+ SAN JOAOUIM AlbTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HF TH DIVISION <br /> STORAGE TANK PROGRAM - FEE WORKS <br /> FACI ITYCONTACT NAM <br /> ,.S FACILITY SITE NAME n �� r 1 <br /> I n <br /> T Si PHONE # With AREA CODE 1 <br /> E FACILITY ADDRE S (_ ,9„C <br /> ) �1,` Ca 4 T <br /> STATEI ZIP CODE # of TANKS <br /> A CITY , ( ,n �f 1 at SITE <br /> P + APPLICANTCONTACT NAME <br /> P APPLICANT/BI LING NAME <br /> L ..iS C, _ ' "Kl <br /> I I APPLI T PHON # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N STA7E �P CODE ` TYPE of APPLICATION <br /> T CITY I �� /1 1 (Closure, Irstallaiion, etc-) <br /> TOTAL <br /> 1986 11987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 XXX% XXXX I XXX% I XXX% XXXX S XXXXXXXXXXXX% <br /> A <br /> C X%XX XXXX I XXXX I XXXX XXXX $ XXXXXXXXXXXXX <br /> T FACILITY PENALTY FEES ASSESSED (If ApplicabLe) <br /> I 5170/TANK (After January 1, 1991) <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) <br /> E 11986 11987 11988 11989 11990 1991 1992 1993 1994 I .995 1996 <br /> # Tanks <br /> F (mu Lt iply # by fee for I I I I S <br /> A each year appLicabl e) XXXX I XXXX I XXXX I XXXX I XXXX <br /> C XXXI %XXX XXXX IXXX% IXXXX <br /> I TANK PENALTY FEES ASSESSED I I I I S <br /> L <br /> IFSTATECHARGE = 556.00 each TANK (Due every 5 years) See California N & S Code, Section 25287 <br /> T 1990 1991 through 1996 <br /> Y x 556.00ount and year) S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.O. #(s) <br /> L # TANK(5)__ % 5234.00 = S <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimm/TANK) <br /> S TANK I.D. #(S) <br /> U TEMPORARY CLOSURE (Plan Review S Inspections) <br /> RS <br /> EI TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minioam/FACILITY) I 5234.00 mini" <br /> P INSTALLATION PLAN CHECK (Plan Review 6 Construction Inscec:icrvS)I TANK I.D. #(s) <br /> L <br /> A = 5624.00 minimm 5 <br /> M PLAN CHECK FEE = 578.00/hour (8 hours minimm/FALILITY) <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) <br /> TANK I.D. #(s) <br /> EI # TANK(s) _ X SZ34.00 = S <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /> A = 5234.00 minimum S <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br /> R = 5234.00 mini mm L <br /> PIP(NG REPALR FEE = 578.00/hour (3 hours minimm/FACILITY) <br /> S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br /> I <br /> 5 5 <br /> 578.00/hr <br /> C CONSULTATION FEE = 578-00/hr I SAMPLING INSPECTION F'cE <br /> TOTAL DUE S .� <br /> FOR OFFICE USE ONLY <br /> — DATE RECEIVED <br /> MORE SWEEPS # COMPUTER # LOC CODE DIS: CODE 1 AMuuni RECEIVED - <br /> RECEIVED ay <br /> S --- --I <br /> _- -..... -._._... =--- _ <br />