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�. <br />SAi1 JOAQUiM Cti1t1NtY PUBLIC HEALTH SERVICE! - ENVIRONMENTAL HEALTH DIYSIOM <br />UMDEROROIIMO STORAGE 7A81( PROGRAM - FEE WORKSHEET <br />S FACILITY SITE NAME FACILITY CONTACT NAME <br />i L <br />T <br />E FACILITY ADDRESS y SIT PHON #with AREA CODE <br />A- 2/ 2,5 <br />CITY STATEJ IiP CODE # of TANKS <br />A <br />/ at SiTE <br />Sri C� C_ K 4 � Cif' �. <br />P <br />P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br />I <br />C MAILING ADDRESS APPLICANT PHOAE # WITH AREA CODE <br />Al) ---7 cJ �;3.� ��a 7��- 390/ <br />M <br />T CITY TAt€ ZiP CODETYPE of APPL _ <br />In ��� (Closure, natelLeti ,etc.) <br />TOTAL <br />1 1987 1988 1989, 1990 <br />A <br />ANNUAL FACILITY FEE ria' Je ry 1, 1991) $100.40 <br />i ! <br />C <br />T FACILITYA Y FEES SSE SSED (if Appiiceble) lxxx xxxx 1 <br />1 <br />V TANK FEE = S 40/ K (Prior to January 1,1991) 11 /TANK (After Januer,y 1, 1991) , <br />E <br />N Tenks = 1986 1987 1988 1 990 1991 1992 1993 1994 1995 1996 <br />F (multiply it ea for <br />A each year appli ble) 1 <br />C <br />I TANK PENALTY FEES SSElSEb xxx xxx <br />L <br />i STATE SURCHARGE ■ 156.00 a h ANI1; (D a ery y re} ee CeIffornia S Code, Section 29787 <br />T <br />Y N Tanks x 156.40 �1986��Jraugh�1990 1991 through 1996 <br />(Enter amount and year) S <br />CPERMANENT <br />CLOSURE (Removal or A thOr�ed C(Aure•in-Place) <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE - 178.00/hour (3 h e min /TANK) <br /># TANK(e) X 1234.00 ■ <br />E <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review i Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE x 178.00/hour (3 hours mini TANK) <br /># TANK(s) X $234,00 ■ <br />1 <br />l <br />P <br />I milli <br />INSTALLATION PLAN CHECK (Plan Revid1 6 Cone uction Inspections} <br />TANK i.D. #(s) <br />L <br />A <br />H <br />PLAN CHECK FEE a 178.00/hour (8 hours FACILITY) <br />■ $624.00 minimum <br />1 <br />R <br />REPAIR FEE (Workplan Review 9 C ructlon Inspections) <br />TANK I.D. #(e) <br />E <br />P <br />TANK LINING REPAIR PEE ■ $78.00/hour (3 hours minima /TANK) <br /># TANK(s) X $234.00 <br />1 <br />A• <br />I <br />TANK RETROFIT REPAIR FEE ■ 8.00/hour (3 hours min./FACILITY) <br />1234,00 minimum <br />1 <br />R <br />PiPING REPAIR FEE ■ 178.00/hour (3 hours mfnimus/FACILiTY) <br />• $234.00 minimus <br />1 <br />M <br />TRANSFER FEE 120.00 UNAUTHORIZED RELEASE EVALUATION ■ 578.00/hr <br />1 <br />I <br />S <br />C <br />CONSULTATION PEE = 178.00/hr SAMPLING INSPECTION FEE <br />■ 178.00/hr <br />1 <br />TOTAL DUE <br />$ 2 3 <br />FOR OFFICE USE ONLY <br />!!T;1•.9!E:3$ieliiP.Yi'dl _��,ittl�illm6i. <br />Iffirlr^t. ftiilil'Jt !fnEi$� <br />SNEEPS # I COMPUTER <br />W -W _........_._. - <br />LOC COR 015T COOS AMOUNT RECEIVED CHECK #/CASII RECEIVED G <br />032 (REVISED 11-1-92) <br />DATE RECEI <br />