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SAI! JOACXIIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH Di SIGN <br />UNDERGRCILAML.STORAGE TANK PROGRAM - FEE WORKSHEET <br />ACILITY SITE NAME I FA ILITY ACT NAME <br />FACILITY ADDRESS SITE PHONE x with AREA CODE <br />. <br />:)TY r .� <br />ST TE ZIP CODE 9 of TANKS <br />at SITE <br />APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br />rG,AOORESS <br />APPLICANT PHONE # WITH AREA CODE <br />CITY I STATE ZIP <br />(Closure <br />CODE TYPE of APPLICATION <br />, Installation, etc.) <br />ANNUAL FACILITY FEE (Prior <br />to January 1, 1991) 5100.00 <br />S <br />1986 <br />1987 <br />1 1 <br />1988 <br />1989 11990 <br />xxxx <br />Xxxxx I <br />S <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />xxxx <br />I xxxx <br />I <br />S <br />TANK FEE = S50.00/TANK <br />(Prior to January 1,1991) <br />5170/TANK <br />(After <br />January 1, 1991) <br />0 Yanks = <br />(multiply # by fee for <br />each year applicable) <br />1986 <br />1987 <br />1988 11989 <br />1990 <br />1991 11992 <br />11993 <br />1994 <br />11995 ( 1996 <br />xxxx <br />xxxx <br />I <br />I I <br />I I I <br />1 <br />TANK PENALTY FEES ASSESSED <br />( xxxx <br />xxxx <br />I <br />I I <br />s <br />STATE SURCHARGE = S56.00 <br />each TANK (Due every 5 years) <br />See California H & S Code, <br />Section 25287 <br />�J <br /># Tanks x 556.00 <br />(Enter amount and year) <br />1 <br />1988 through 1990 <br />1991 through 1996 <br />1 <br />s <br />PERMANENT CLOSURE (Removal or Authorized Closure-in-P(ace) I TANK I.D. 1(s) <br />CLOSURE FEE = 578,00/hour (3 hours minimum/TANK) 1 TANK(s) X 5234.00 = S <br />TEMPORARY CLOSURE (Plan Review & Inspections) TANK [.D_ $(s) <br />TEMPORARY -CLOSURE FEE s 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum 1 <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. x(s) <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br />REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. 2(s) <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = <br />S <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br />S <br />PIPING REPAIR FEE = 178.00/hour (3 hours minimum/FACILITY) = 1234.00 minimun <br />T <br />I TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I 5 <br />I � <br />CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE = 578-00/hr S <br />TOTAL DUE S <br />IFFICE USE ONLY <br />EPS # I COMPUTER # I LOC CODE I DIST CODE AMOUNT RECEIVED _I CHECK »/CASH I RECEIVED 3Y ^I DATE RECEIVED <br />23 032 (REVISED 10-28-93) 3 <br />a <br />0 <br />