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SAN J0Aa1IN COUIT .ELIC HEALTH SERVICES - ENVIROMMMAL HEALT fSION <br /> LIMDERGROUD STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SFACILITY SITE NAME FACILITY CONTACT NAME <br /> I <br /> T L NarktztJames—Fisk, <br /> F VACILITY ADDRESS SITE PHONE # with AREA CODE <br /> CITYWa <br /> TE ZIP CODE # of TANKS <br /> P French Cam 95231 at SITE three <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A 8115 South ElDorado Street 209 982 0897 <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX )OM XXXX S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXX)( XXXX xxxx S <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 11988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply T-Sy—fee for <br /> A each year applicable) XXXX )o= I X)00( $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX )o= I )D= 5 <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 <br /> CLOSURE FEE = $78.00/hour (3 hours mini4aJTANK) # TANK(s) X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> 'EMPORARY CLOSURE FEE = $78.00/hour (3 hours minimun/FACILITY) 5234.00 minimus S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> NJ PLAN CHECK FEE = S78.00/hour (8 hours miniam/FACILITY) = S624.00 minimum $ <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum s <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours ■inimua/FACILITY) = SZ34.00 minimum S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE S 70p,no <br /> –MR–QUI_,CE–USE-94.4�Y <br /> .....................rERol,Nr—arc tv� -T—CH C1(�a%CASH kf-CE1�/i15 9!:: AT –RECEIVED `_ <br /> t, <br /> EH 23 032 (REVISED 4-29-94) Page <br />