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SAM JOAQUIN CCIft PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE• DIVSI011 <br />UNIWROUMD STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SIT& NAME <br />I <br />FACIL�ITY//CONT//ACT NAME I Q/� <br />I <br />/ I <br />W 4 x'�- GT -e <br />T <br />E <br />FACILITY ADDRESS1 <br />SITE PHONE # with AREA CODE <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />5 (c- <br />IeIZ67 <br />R <br />c� <br />S <br />& <br />E <br />P <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />A <br />I <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS Z <br />SITE <br />A <br />= $234.00 minimum <br />CY <br />95:JZC <br />at <br />S <br />O h <br />M <br />TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />S <br />P <br />P <br />APPLICANT/BILLING <br />//�� <br />APPLICANT CONTACT NAME <br />L <br />/NAME <br />l,/a /A-' e i2a- <br />er rr) L <br />I <br />C <br />MAILING ADORE <br />APPLICANT PHONE # WITH AREA CODE <br />(�� <br />T <br />N <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />k <br />A <br />r5314 a <br />(Closure, Installation, etc.) <br />p <br />TOTAL <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) Z X $234.00 = <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />CHECK #/CASH <br />RECEIVED BY DATE RECEIVEDi <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />S <br />s <br />E <br />P <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />A <br />R <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimuNFACILITY) <br />= $234.00 minimum <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimu VTANK) <br />$ <br />S <br />M <br />TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />S <br />I <br />C <br />S <br />CCNS <br />TATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br />= 578.00/hr <br />$ <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX <br />S <br />I <br />V <br />TANK FEE 550.00/TANK (Prior to January 1,1991) <br />8170/TANK (After January 1, 1991) <br />E <br /># Tanks = <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />1991 <br />1992 <br />199I <br />994 <br />1995 <br />1996 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) <br />S <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />$ <br />L <br />I <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br />T <br />Y <br /># Tanks x 856.00 <br />1986 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />S <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />...,...:..ii!!!:ii::�::.:_,_:_��,.uwinrJ.::,..x�_�....u...:..::,,,..:.:.!,,.,:i <br />L <br />A <br />N <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) Z X $234.00 = <br />$ <br />CHECK #/CASH <br />RECEIVED BY DATE RECEIVEDi <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />S <br />s <br />E <br />P <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= S234.00 minimum <br />R <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimuNFACILITY) <br />= $234.00 minimum <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimu VTANK) <br /># TANK(s)_ X 5234.00 = <br />S <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />...,...:..ii!!!:ii::�::.:_,_:_��,.uwinrJ.::,..x�_�....u...:..::,,,..:.:.!,,.,:i <br />L <br />A <br />N <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) <br />$624.00 minimum <br />S <br />DIST CODE <br />AMOUNT RECEIVED <br />CHECK #/CASH <br />RECEIVED BY DATE RECEIVEDi <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />s <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) _ X 5234.00 = <br />$ <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= S234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimuNFACILITY) <br />= $234.00 minimum <br />$ <br />M <br />TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />S <br />I <br />S <br />CCNS <br />TATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br />= 578.00/hr <br />$ <br />TOTAL DUE $ <br />6 <br />FOR OFFICE USE ONLY <br />..... ...................._... <br />.... .::................. <br />_................. <br />:.t:........................:........::....:.-::::::::.......:. <br />...._.... :.... <br />...,...:..ii!!!:ii::�::.:_,_:_��,.uwinrJ.::,..x�_�....u...:..::,,,..:.:.!,,.,:i <br />_ <br />.... i. �.e, i.i_imia!i:a��i:iii::i.ii:i:.i::i:: <br />SWEEPS # <br />COMPUTER # LOC CODE <br />DIST CODE <br />AMOUNT RECEIVED <br />CHECK #/CASH <br />RECEIVED BY DATE RECEIVEDi <br />a 5 <br />Z6 <br />s <br />i <br />.................................._._................._._ <br />_............ <br />__ ...._._............... <br />.,!.,.. <br />.::.,:::--_.... <br />E!::' .. u!::_i�i��'.iiiE___,:::::v_:�!!!iii!S!ii!iiii!iii!ilii!iiiiiiiiifJiiF_8i!i!�92",c�_Iu14ii:i�iiiP1 <br />.vi..,ll <br />. ...__..._.__.—._.............. <br />......_...........!ii!iii:-::e::::::::::::::....:.:..::::::::::::.::iii:!i <br />� :! <br />EH 23 032 (REVISED 11-1-92) <br />