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(0 � �HLTH SAN J0� PUBLIC SERVICES - ENVIRONMENTAL HE I <br />UNDERGROUND STORAGE TANK PROGRAM - FEF LnartNvVT T-1 --- 71 <br />R <br />REPAIR FEE (Workplan Review & Construction inspections) TANK I.D. #(s) <br />E <br />S <br />FACILITY SITE NAME <br />FACILITYCONTACTNAME %V, zJ' <br />T <br />A <br />�v-/ <br />8 <br />FACILITY ADDRESS / <br />V <br />SITE P� �� pA�RE_A CODE <br />C <br />v <br />u 7 <br />A <br />CITY ' <br />STATk I ZIP Cam / <br />b <br /># of TANKS <br />SITE <br />P <br />V <br />J <br />at <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CON ACT NAM <br />I <br />C <br />MAILING ADDR SS ' <br />APPLICANT PHONE # WITH AREA CODE <br />F <br />(multiply # by fee for <br />hN �� U Sv /�j USI, STATE ZIP CODE TYPE of APPLICATION <br />s� <br />each year applicable) <br />Closure, Installation, <br />R <br />REPAIR FEE (Workplan Review & Construction inspections) TANK I.D. #(s) <br />E <br />TOTAL <br />P <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />1986 1987 1988 1989 1990 <br />A <br />A <br />I <br />5 <br />C <br />R <br />T <br />I <br />FACILITY PENALTY FEES ASSESSED (if Applicable) <br />XXXX XXXX <br />; <br />V <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br /># Tanks 1986 1987 1988 1989 1990 <br />1994 1995 1996 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) <br />!1991 E19921993 <br />5 <br />C <br />I <br />TANK PENALTY FEES ASSESSED XXXX XXXXH- <br />$ <br />L <br />I <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T <br />Y <br /># Tanks x $56.00 <br />1966 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = <br />5 <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimun/FACILITY) <br />= S234.00 minimum <br />; <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction tions) <br />TANK I.D. #(s) <br />L <br />A <br />AN CHECK FEE = S7$.00/hour (8 hours minimum/FACILIT <br />: $624,00 minimum <br />; 6 <br />R <br />REPAIR FEE (Workplan Review & Construction inspections) TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 ■ <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE is 578.00/hour (3 hours min./FACILITY) = $234.00 mininxm <br />$ <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />; <br />M TRANSFER FEE = $20.00 <br />1 <br />S <br />C CONSULTATION FEE = $78.00/hr <br />FOR OFFICE USE ONLY <br />UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />SAMPLING INSPECTION FEE �= 578.00/hr <br />s <br />S <br />TOTAL DUE 1 S <br />7q <br />2 <br />