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�jc <br />w SAN JOAOUINONTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL TH D)VSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET �3 <br />S FACILITY SITE NAMEFACILITY CONTACT NAME <br />I S 5 / J G v <br />T <br />E FACILITY ADDRESS a/ ' jL ' 1 V SITE PHONE !_Mith AA — /� 65 <br />CITY � � STATE ZIP CODE # Of TANKS <br />A at SITE <br />P APPLICANT E <br />��� <br />P APPLICANB1LLiNG NAME C/V T� <br />T/ <br />Lke <br />• ri l <br />I <br />A MAILING ADDRESS _ b L 61, <br />APPLICANT PHONE # WITN AREA CODE <br />I D S i� <br />N <br />CITY Z d S U N 1Ri a STATE ZIP CODE TYPE of APPLICATION <br />J re, Installation, etc.) <br />T ) G�05 U <br />.� TOTAL <br />1986 1987 1988 1989 1990 <br />ANNUAL FACILITY FEE (Prior'to January 1, 1991) ¢ $100.00 $ <br />A <br />C S <br />T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX <br />I <br />V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br />E 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br />#Tanks <br />= <br />F (multiply # by fee for S <br />A each year applicable) qqA- <br />C <br />ITANK PENALTY FEES ASSESSED XXXX XXXX IDD 0 o 5 L <br />L <br />I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T 1991 through 199b <br />Y #Tanks x $56.00 1986 through 1990 5101 <br />(Enter amount and year) S <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. k a) <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = <br />S <br />S <br />u <br />TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. *(a) - <br />R <br />E <br />P <br />FTEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum <br />S <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. X(s) <br />L <br />A= $624.00 minimum S <br />N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) <br />R <br />REPAIR FEE (Workplan Review & Construction inspections) <br />TANK I.D. #(s) <br />E5 <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X S234.00 = <br />A <br />1 <br />TANK RETROFIT REPAIR FEE = E78.00/hour (3 hours min./FACILITY) <br />= $234.00 minimum S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= S234.00 minimum S <br />M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />1 ' <br />S <br />C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br />TOTAL DUE <br />FOR OFFICE USE ONLY <br />S <br />M---------- ---------- -- -- • <br />EH 23 032 (REVISED 3-1-931 0 <br />Paae 11 <br />S <br />s <br />S <br />