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SAN J0110UIM CT PUBLIC HEALTH SERVICES - ENVIRONMENTAL I`, IH DIVSION <br />GROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />I <br />FACILITY SITE NAME <br />1986 <br />FACILITY CONTACT NAME <br />1988 <br />1989, <br />1990 <br />_..cac-_:::::a::e::x:=e:::.=:c::�:n.:::.,!._..:a!!_::o <br />T <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) in 5100.00 <br />P <br />E <br />a <br />FACILITY ADDRESS <br />7�7 J/ <br />SITE PHONE # with AREA CODE <br />S <br />CITY <br />STATE ZIP CODE # of TANKS <br />A <br />at SITE <br />_ <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) in $234.00 minimum <br />P <br />R <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />C <br />I <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />N <br />I <br />V <br />TANK FEE in 550.00/TANK (Prior to January 1,1991) <br />$170/TANK (After January 1, 1991) <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br /># Tanks in <br />7986 <br />1987 <br />7988 <br />(Closure, Installation, etc.) <br />TOTAL <br />P <br />INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) <br />1986 <br />1987 <br />1988 <br />1989, <br />1990 <br />_..cac-_:::::a::e::x:=e:::.=:c::�:n.:::.,!._..:a!!_::o <br />SWEEPS # COMPUTER # LOC CODE DIST CODE <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) in 5100.00 <br />P <br />TANK LINING REPAIR FEE = 278.00/hour (3 hours minimFs/TANK) <br />N <br />PLAN CHECK FEE - S78.00/hour (8 hours miniman/FACILITY) in 2624.00 minimus <br />S <br />a <br />A <br />s_-:::—tmae!x:xx!e.®=�xP��rt,_ <br />_ <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) in $234.00 minimum <br />5 <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) in $234.00 minimum <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX <br />2 <br />I <br />V <br />TANK FEE in 550.00/TANK (Prior to January 1,1991) <br />$170/TANK (After January 1, 1991) <br />E <br /># Tanks in <br />7986 <br />1987 <br />7988 <br />7989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1 1995 <br />1996 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) <br />$ <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXKK <br />xXxX <br />S <br />L <br />1 <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 $56.00 <br />1986 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />s <br />, <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />o <br />CLOSURE FEE - 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) K $234.00 <br />q <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review 8 Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/TANK) <br /># TANK(s) X $234.00 = <br />S <br />P <br />INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) <br />TANK I.D. #(s) <br />E <br />-som:-:'::::. ;...__...:::::ea::::i:::na iiiii. <br />=::na::v::n_ ::_ :: <br />L <br />_..cac-_:::::a::e::x:=e:::.=:c::�:n.:::.,!._..:a!!_::o <br />SWEEPS # COMPUTER # LOC CODE DIST CODE <br />A <br />P <br />TANK LINING REPAIR FEE = 278.00/hour (3 hours minimFs/TANK) <br />N <br />PLAN CHECK FEE - S78.00/hour (8 hours miniman/FACILITY) in 2624.00 minimus <br />S <br />R <br />REPAIR FEE (Workplan Review 8 Construction Inspections) <br />TANK I.D. #(s) <br />E <br />-som:-:'::::. ;...__...:::::ea::::i:::na iiiii. <br />=::na::v::n_ ::_ :: <br />....::.:: .-H-1-::-...:r:::::_'U <br />_..cac-_:::::a::e::x:=e:::.=:c::�:n.:::.,!._..:a!!_::o <br />SWEEPS # COMPUTER # LOC CODE DIST CODE <br />AMOUNT RECEIVED <br />P <br />TANK LINING REPAIR FEE = 278.00/hour (3 hours minimFs/TANK) <br /># TANK(s) X $234.00 = <br />9: <br />A <br />a <br />s_-:::—tmae!x:xx!e.®=�xP��rt,_ <br />_ <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) in $234.00 minimum <br />8 <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) in $234.00 minimum <br />$ <br />TRANSFER FEE in $20.00 <br />CONSULTATION FEE in S78.00/hr <br />FaR nFFIrF USF 01HY <br />UNAUTHORIZED RELEASE EVALUATION in 578.00/lir <br />SAMPLING INSPECTION FEE in S78.00/hr <br />S <br />S <br />TOTAL DUE 1 2 <br />M_e.:Y_�.='_.i9E:Jxe1T.:lix:litTni!^!e3!!3!i!M114!.^_?iiF.!!C:.m161:_aT_iFie.4':51:51�d3x'w.R!!ih::xxii::=!-±5!aFlim_:_mti <br />_:'s„[a <br />-som:-:'::::. ;...__...:::::ea::::i:::na iiiii. <br />=::na::v::n_ ::_ :: <br />....::.:: .-H-1-::-...:r:::::_'U <br />_..cac-_:::::a::e::x:=e:::.=:c::�:n.:::.,!._..:a!!_::o <br />SWEEPS # COMPUTER # LOC CODE DIST CODE <br />AMOUNT RECEIVED <br />CHECK #/CASH <br />RECEIVED BY GATE RECEIVEDin <br />M <br />a <br />s_-:::—tmae!x:xx!e.®=�xP��rt,_ <br />-T!n:.ys-!acx!: ^_+:±;�:s!!�'�s�_=_= <br />._..._......,,:..,._.,.__.;. n... .n:. :._.,. .___..,.__ .; .r.__..._:.....--.�:: <br />=tiu.��'nnnm-ii!. iSilLiSxu_.�I:axk.�A:2. <br />t--:-=:n_::..::-:::::n <br />T .�_.._..a.:.v___F <br />!!=.r:!:c.as!m!!xE�!.=.xr:!!!�!'-!�m!!:i!xs <br />:: .n:- -' <br />�nll!iFinF.!xc!Sve!i"i+=i!x:ix'!x:::!x_ <br />:uu!!o_ ••••• s::9!„xsxxexnxn.!m!-i <br />'' __ ___ __ �Sxxxx..1!!x!5!:!=!!!.:r�c�a!nar:!!.y <br />EH 23 032 (REVISED 11-1-92) Page 11 <br />