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SAN JOAcXIIN COUNTY mW -IC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />UNOERGRajm STORAGE TANK PROGRAM - FEE WORKSHEET <br />S� <br />FACILITY SITE NAME <br />FACILI Y CONTACT NAME <br />L <br />L <br />0 <br />fUTA1. <br />T <br />E <br />FACILITY ADDRESS <br />V' r� r ed <br />SG+I�TE PHONE x with AREA CODE <br />® --/6 7 <br />1986 11987 <br />CITY <br />® <br />SATE <br />ZIP CODE <br />'� �? <br />9 of TANKS <br />at SITE <br />A <br />(�c;► <br />�I <br />GAr <br />P <br />/ <br />APPLICANJ/SILLINI NAME <br />j <br />APPLICANT qN T NAME r�� � <br />L <br />�t�e <br />XXXX 1 <br />C <br />M <br />NAI ,G/}AOOR Ski <br />�4° <br />APPLICIH PHONE if Wt7� AREA C0� <br />/I /iJ 2.PC <br />T <br />CITya(i? <br />- elf <br />S TE <br />�f® <br />ZIP CODE <br />�LtT Z3 <br />TYPE of APPLICATION G P4 V <br />(Closure, Installation, etc.)•' <br />� <br />C <br />PERMANENT CLOSURE (Removal or Authorized C:osure-in-Place) I TANK I.D. X(s) <br />TANK I.O. 1(s) <br />L <br />L <br />0 <br />fUTA1. <br />_ <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. x(s) <br />1986 11987 <br />11988 <br />1989 11990 <br />TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum <br />3 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) - 5100.00 <br />PIPING REPAIR FEE = 378.00/hour (3 hours xinimum/FACILITY) = 1234.00 minimum <br />s <br />A <br />XXXX <br />XXXX 1 <br />S <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />xxxx <br />XXXX <br />1 <br />I <br />V <br />TANK FEE _ $50.00/TANK (Prior to January 1,1991) <br />5170/TANK <br />(After January 1, 1991) <br />E <br /># Tanks = <br />1986 <br />1 1987 1988 11989 ( <br />1990 <br />1991 ( 1992 ( <br />1993 ( 1994 <br />11995 1996 <br />F <br />(multiply x by fee for <br />f <br />A <br />each year applicable) <br />E <br />XXXX i <br />I I <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />I XXXX <br />XXXX <br />L <br />I <br />STATE SURCHARGE = 556.00 each TANK (Due every 5 years) <br />See California H & S Code, Section 25287 <br />T <br />Y <br />9 Tanks x 356.00 1988 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />S <br />C <br />PERMANENT CLOSURE (Removal or Authorized C:osure-in-Place) I TANK I.D. X(s) <br />TANK I.O. 1(s) <br />L <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimus/TANK) 9 TANK(s) X 3234.00 = <br />_ <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. x(s) <br />0 TANK(s) X s234.00 = <br />3 <br />R <br />E <br />TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum <br />3 <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Carstruction Inspections) <br />TANK I.O. 1(s) <br />L <br />A <br />N <br />PLAN CHECK .'EE _ $7a.00/hour (8 hours mini=xa,'FACILITY) _ 5624.00 minim87n <br />3 <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. x(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br />0 TANK(s) X s234.00 = <br />3 <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.001hour (3 hours min./FACILITY) = 5234.00 minimum <br />3 23 <br />R <br />PIPING REPAIR FEE = 378.00/hour (3 hours xinimum/FACILITY) = 1234.00 minimum <br />s <br />NI TRANSFER FEE = 320.00 I UNAUT:ICRIZED RELEASE EVALUATION = 178.00/hr I I 3 <br />I <br />S <br />C CONSULTATION FEE = 378.00/hr I I SAMPL:xG INSPECTION FEE - s78.001hr 3 <br />TOTAL DUE S <br />FOR OFFICE USE ONLY <br />EM <br />_._..._...._ _._..._.._._......_ .__.._... __.�..._...__._..__.._..__._...... <br />__...._........�....:..._.....__.._.._.� 3 - <br />N•s.._.r.,le_.._•313«'..^.�^�«y^.'�...'�':�•_•CC�:•L:::' �.�.� .�yy__:•_ ' _..... _.._._.__�__.�_•r_•. �L__.L._.. <br />SWEEPS 4 I COMPUTER 1 LOC CODE I DIST =OE I AMOUNT RECEIVED I CHECK I/CASH 1 RECEIVED 3Y I DATE RECEIVED <br />i IF s I I � <br />EH 23 032 (REVISED 10-28-93) 3 <br />