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S FACILITY SITE NAME <br />I� <br />T ` <br />E FACILITY ADDRESS <br />fY <br />P APPLICANT/BILLING NAME <br />I TZ <br />C NAILING ADDRESS <br />9— <br />°1 <br />T CITY <br />SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />UNDER' 'D STORAGE TANK PROGRAM - FEE WORKSHEET <br />FACILITY CONTACTNAME <br />, <br />ISS ---}rel <br />SITE PHONE # with AREA CODE <br />STATE ZIP COOE # of TANKS <br />G� 4f,- <br />4: at SITE <br />APPLICANT CONTACT NAME <br />�4✓ <br />APPLICANT4Z, /# W(I�TH CODE <br />STNE ZIP CODE06q TYPE of APPLICATION <br />(Closure, InstaLLation, etc.) <br />TOTAL <br />C <br />,ERMANENT CLOSURE (Removal or Authorized Closure-in-P(ace)TANK <br />I.D. #(s) <br />L <br />1986 <br />1 <br />1987 <br />1988 11989 <br />1 <br />1490 <br />1 <br />S <br />0 <br />ANNUAL FACILITY FEE (Prior <br />to January 1, 1991) - S100.00 <br />S <br />S <br />I <br />TANK RETROFIT REPAIR FEE - S78.00/hour (3 hours min./FACILITY) = S234.00 minimumS� <br />7 C'4 <br />XXXX <br />I XXXX <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />S <br />A <br />C <br />S <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />S <br />T <br />FACILITY PENALTY FEES ASSESSED <br />(If Applicable) <br />XXXX <br />XXXX <br />+ <br />S <br />I <br />V <br />TANK FEE 550.00/TANK <br />(Prior <br />to January 1,1991) <br />5170/TANK <br />(After <br />January 1, 1991) <br />E <br /># Tanks <br />1986 <br />1987 <br />1988 1989 <br />1990 <br />1991 11992 <br />11993 <br />11994 <br />11995 11996 <br />F <br />(multiply # by fee for <br />XXXX <br />S <br />A <br />C <br />each year applicab(e)XXXX <br />I <br />TANK PENALTY FEES ASSESSED <br />I XXXX <br />XXXX I <br />S <br />L <br />I <br />STATE SURCHARGE = S56.00 <br />each TANK <br />(Due every 5 years) <br />See California H I S Code, <br />Section 25287 <br />T <br />Y <br />4 Tanks x 556.00 <br />1988 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />S <br />C <br />,ERMANENT CLOSURE (Removal or Authorized Closure-in-P(ace)TANK <br />I.D. #(s) <br />L <br />N <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />S <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimua/TANK)I # TANK(s) X S234.00 = <br />S <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = <br />S <br />S <br />I <br />TANK RETROFIT REPAIR FEE - S78.00/hour (3 hours min./FACILITY) = S234.00 minimumS� <br />7 C'4 <br />R <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. J(s) <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimun/FACILITY) = $234.00 minimum <br />S <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />S <br />PI <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />S <br />R <br />REPAIR FEE (Workplan Review 3 Construction Inspections)I TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimua/TANK)I # TANK(s) X S234.00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE - S78.00/hour (3 hours min./FACILITY) = S234.00 minimumS� <br />7 C'4 <br />R <br />J <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimun/FACILITY) = $234.00 minimum <br />S <br />NI TRANSFER FEE - S20.00 I UNAUTHORIZED RELEASE EVALUATION = 378.00/hr <br />I i I <br />S <br />C CONSULTATION FEE - 578.00/hr I I SAMPLING INSPECTION FEE = S78.00/hr <br />S <br />S <br />TOTAL DUE S <br />Fc" `FFICE USE ONLY <br />_ w_PS # COMPUTER LOC CODE DIST CODE AMOUNT RECEIVED I CHECK #/CASH RECEIVED 3Y <br />I 15 I <br />EH 23 032 (REVISED 10-28-93) 3 <br />`r. <br />DATE RECEIVED <br />