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SAII JOAQUIN COLMT LIC HEALTH SERVICES - ENVIRONMENTAL HEALT VSION <br /> / / tMERI AQ STORAGE TANK PROGRAII - FEE UORKSHEET <br /> S FACILITY SITE NAME q FACILI CONTACT N E <br /> E FACILITY ADDRESS SITE PHONE R with AREA CODE <br /> CITY STATE ZIP CODE N of TANKS <br /> P <br /> A 1( C� r, C at SITE <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> 1. tt� <br /> 1 <br /> C MAILING ADDRESS APPLICANT PHONE 0 WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (0lesure, Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) ' !100.00 <br /> 1986 1987 1988 1989 1990 <br /> A <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx = <br /> I <br /> V TANK FEE 150.00/TANK (Prior to January 1,1991) 6170/TANK (After January 1, 1991) <br /> E <br /> N Tanks ■ 1986 1987 1968 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply W-fee for <br /> A each year applicable) <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx It <br /> 1 STATE SURCHARGE ® 156.00 each TANK (Due every 5 years) $ee California N t S Code, Section 25287 <br /> T <br /> Y R Tanks x 156.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> ! <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-In-place) TANK I.D. /(s) <br /> L <br /> 0 CLOSURE FEE ■ 178.00/hour (3 hours minlmum/TANK) 0 TANK($) x $234.00 ■ 5 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review t Inspections) TANK I.D. fl a) <br /> R <br /> E TEMPORARY CLOSURE FEE ■ 078.00/hour 0 hours minlmum/TANK) A TANK(s) X !234.00 ■ ! <br /> P INSTALLATION PLAN CHECK (Plan Review i Construction InspectloM) LANK I.D. N(sD <br /> L <br /> A o <br /> N PLAN CHECK FEE ■ 478.00/hour (8 hours mintaWfACILITY) • 9624.00 minimus ! <br /> R REPAIR FEE (Workplan Review t Construction Inspections) TANK I.D. N(a) <br /> E <br /> P TANK LINING REPAIR FEE ■ !78.00/hour (3 hours minimnVTANK) N TANK(*) <br /> A X 0234.00 ' ! <br /> I TANK RETROFIT REPAIR FEE ■ 978.00/houh 0 hours min./FACILITY) ■ !234.00 minimus ! <br /> R <br /> PIPING REPAIR FEE ' !78.00/hour (3 hours minimun/FACILITT) ■ !234.00 minimus ! <br /> N TRANSFER FEE ■ !20.00 UNAUTHORIZED RELEASE EVALUATION ■ !78.00/hr ! <br /> i <br /> S <br /> C CONSULTATION FEE * 178.00/hr SA14PLINO INSPECTION FEE ■ 0 <br /> 78.00/hr : <br /> TOTAL DILE <br /> Fat OFFICE USE ONLY <br /> SWEEPS I COMPUTER 11 LOC CODE DIST CODE AMOUNT RECEIVED CHECK N/CASH RECEIVED 8Y DATE RECEIVED <br /> 1-0 Mug f N� �3t1�3 _( �_ <br /> {�;ini in i n <br /> EH 23 032 (REVISED 11 1-92D Pape 09 <br />