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v <br />S FACILITY SITE NAME <br />I <br />T <br />E FACILITY ADDRESS <br />& <br />CITY <br />A <br />P <br />P APPLICANT/BILLING NAME <br />L <br />I <br />C MAILING ADDRESS <br />A <br />N <br />TI CITY <br />SAN JQAQtJINd&NTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL "ALTH DIVISION <br />GROUND STORAGE TANK PROGRAM - FEE WORKSHE <br />FACILITY CONTACT NAME <br />SITE PHONE # with AREA CODE <br />STATE ZIP CODE # of TANKS <br />at SITE <br />APPLICANT CONTACT NAME <br />APPLICANT PHONE # WITH AREA CODE <br />STATE ZIP CODE I TYPE of APPLICATION <br />(Closure, Installation, etc.) <br />TOTAL <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />0 <br />ANNUAL FACILITY FEE (Prior <br />to January 1, 1991) _ $100.00 <br />$ <br />S <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ XXXXXXXXXXXXX <br />A <br />R <br />E <br />TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />$ <br />C <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ XXXXXXXXXXXXX <br />I <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />V <br />TANK FEE _ $50.00/TANK <br />(Prior <br />to January 1,1991) <br />$170/TANK <br />(After <br />January 1, 1991) <br />A <br />I <br />TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) <br />_ $234.00 minimum <br />$ 9 (34- DD <br />E <br />PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) <br />_ $234.00 minimum <br />$ <br />M <br />TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />$ <br /># Tanks = <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />C <br />F <br />(multiply # by fee for <br />$ <br />TOTAL DUE <br />$�(� OO <br />FOR OFFICE USE ONLY <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ <br />A <br />each year applicable) <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX XXXX <br />XXXX <br />XXXX <br />$ <br />L <br />I <br />STATE SURCHARGE _ $56.00 <br />each TANK <br />(Due every 5 <br />years) <br />See California H & S Code, <br />Section 25287 <br />T <br />Y <br /># Tanks x $56.00 <br />1988 through <br />1990 <br />1991 through 1996 <br />(Enter amount and year) <br />j <br />:I <br />$ <br />I <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />$ <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) <br />_ $624.00 minimum I[$ <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />A <br />I <br />TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) <br />_ $234.00 minimum <br />$ 9 (34- DD <br />R <br />PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) <br />_ $234.00 minimum <br />$ <br />M <br />TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />$ <br />I <br />S <br />C <br />CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE <br />_ $78.00/hr <br />$ <br />TOTAL DUE <br />$�(� OO <br />FOR OFFICE USE ONLY <br />