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SAW JOAOUIN PUBLIC HEALTH SERVICES - ENVIRONMENTALH DIVSION <br /> GROUND STORAGE TANK PROGRAM - FEEWORKSHE$ <br /> SI FACILITYNAME_ I FACILITY CONTAC;L T NAME <br /> I L <br /> T <br /> E FACIL TY ADDRESS SIt PHONE # with AREA CODE <br /> & bn <br /> CITY A E ZIP CODE # of TANKS <br /> A at SITE <br /> P <br /> P AP LICANT/BILLING NAME AP ICANT CONT T JOE <br /> h ert LL <br /> A NAILING AI) RESS e APPLICANT PHONE # WITH AREA <br /> N 6 1 <br /> Tj CIT Y TATE ZIP CODE I TYPE of APPLICATION ° <br /> (� (Closure, installation, at <br /> TOTAL <br /> 1986 1987 11988 11989 + 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A X)CXX XXXX ( S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If App(icable) XXXX X)OIX I S <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) S170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 T 1987 1988 11989 1990 1991 11992 11993 ` 1994 1 1995 1996 <br /> F (muttipty # by fee for <br /> A each year applicable) XXXX ff <br /> S <br /> I TANK PENALTY FEES ASSESSED I XXXX ( I I S <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> T # Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removat or Authorized Ctosure-in-Ptace) ( TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = f <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & inspections) TANK I.O. #(s) <br /> R <br /> E I TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum5 <br /> P INSTALLATION PLAN CHECK Man Review & Construction Inspections) TANK 1.0. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hoar (8 hours minimum/FACILITY) = S624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction I tions) TANK I.O. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hoar (3 hours minim WTANK) I # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S 2 <br /> N! TRANSFER FEE = S20.00 I ( UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr I I SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE s ts� <br /> FOR OFFICE USE ONLY <br /> SWEEPS At COMPUTER # LOC CODE I OtST CODE I AMOUNT RECEIVED I CHECK #/CASH ( RECEIVED 3Y I DATE RECEIVED <br /> 1 07 3i 15 T3 4 ! g:8110 EH 23 032 (REVISED 10-28-93) 3 <br />