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SAN JOAoum (0.1✓/PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEAba/DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FE WORKSHEET <br /> 5, FAC:L[TY S r H c i FACI T CONTACT NA <br /> ? - •pr I SITE PH E with AREA CODE <br /> A .•T" A E� P CODE # of TANKS <br /> at SITE <br /> P ck <br /> r APPLICANT CONT <br /> Li <br /> A E <br /> P� APPLICANT/BILLING N / m !h <br /> T <br /> L NAILING ADDRESS G APPL1 N7 PSN VITN AREA E <br /> Al C� J`�U� Y �— — <br /> N <br /> T CITY <br /> J� n� TE• (.tJ (Closure, IroCATION ion, ate.) <br /> f� /C f TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 )DCO( <br /> XXX)( 5 <br /> A <br /> C <br /> T, FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX 307C% 5 <br /> VI TANK FEE = 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> EI # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 11946 <br /> F (multiply8-Tyfee for 5 <br /> Al each year appLicablU )=) X)= <br /> C' I <br /> 11 TANK PENALTY FEES ASSESSED XXX% XXX% S <br /> L <br /> 11 STATE SURCHARGE • 556.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> TI " Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) S <br /> Ci PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(a) 30 33 <br /> L. <br /> 01 CLOSURE FEE = 578.00/hour (3 hours minima/TANK) # TANK(s) X 5234.00 = $ C7 — <br /> S: iv U <br /> UI TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) 992 D <br /> III <br /> EI TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimua/FACILITY) 5234.00 minimae $ <br /> P� INSTALLATION PLAN CHECK (Plan Review 8 Construction ImOactions)I TANK I.D. #(s) <br /> L' <br /> i Al PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITT) = 5624.00 minimum S <br /> RI REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #Cs) <br /> PI TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 = S <br /> II TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum ; <br /> R minimum/FACILITY) - 5234.00 minimm s <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br /> MI TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I' <br /> S' S <br /> C: CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br /> TOTAL DUE $ <br /> Fd(_OfFIS,,�.V$f__pl(•_7_==._...____.__....____.__ _ _ .-:—_____—:____. ..___:-: ... _ ._. �a <br /> Sup�T+�3 1 O'oMDU1'€R �bC C'OOE J—DIST—COOE AMOUNT'—RECEIVEO j�HEtY.��/CASA�RECEIVED 3 � DA7�RECEIVED _ <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />