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SAN JOACUINPUBLIC HEALTH SERVICES - ENVIRONMENTALETH DIVSION <br /> GROUND STORAGE TANK PROGRAM - FEE WORKSH <br /> S FACILITYS TE4AMEFACILITY CONTACT NAME <br /> I <br /> T <br /> E FACILITY ADDRESSf SITE PHONE with AREA CODE <br /> CITYOt <br /> E ZIP CODE # of TANKS <br /> P L-62/7 <br /> at SITE <br /> P APPco <br /> NT BILLING j1AME APPLICANT CONTACT NAME <br /> L c _ � C ry, 1 �.�. <br /> C MAIGfADDRES APPLICANT PN E # WITH AREA CODE <br /> . (gyp t (f <br /> T CITY ? ZIP CODE TYPE of APPLICATION 1-&*p(zjjsr� <br /> ( (Closure, Installation, y��l�y,,� <br /> (�a TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX XXXX $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX 5 <br /> 1 <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX $ <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX XXXX I XXXX XXXX $ <br /> L <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x 356.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = E <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 378.00/hr SAMPLING INSPECTION FEE = 578.00/hr $ <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> ,.. - <br /> MEM MMM <br /> „•, .„; . <br /> m SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> e <br /> :.._.._.. .�.—..—..�...:_. _._.. .._........_.. ...._._..._.._.� - --�,: .�.. p.m::µ�..= <br /> EH 23 032 (REVISED 4-6-95) <br />