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//� <br /> SAM JOAQUIN CCx31TY PUBLIC HEALTH SERVICES - ENVIROMMENTAL HEALTH 01KION <br /> URDERGRa= STORAGE TANK PROGRAM - FEE YCRKSHEET <br /> SI FACILITY SITE NAME / FACILITY CONTACT NAME <br /> 1 JI/ / l' <br /> E FACILITY ADORESS _ SITE PHONE 3 with AREA CCOE <br /> L <br /> A <br /> CITY`� r G 'TATE ZIP��O at of SITE KS <br /> P �/ -fvt <br /> P APPLICANTISILLING NAME APPLICANT CONTACT NAME <br /> L �- <br /> C <br /> HAILING ORE <br /> APICANT P ONE Y WITH <br /> 4INoSa <br /> �a ao9 : E-C <br /> 33 <br /> CITY <br /> STATE ZIP CODE TYPE of APPLICATION <br /> ION <br /> (Closure, Installo cion, etc.) <br /> TOTAL <br /> 1986 1987 11988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior :o January 1, 1991) $100.00 <br /> A KXT( =cc LZ Im- /00. S aQ , <br /> C _ <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) "Of )0(XX 60. Il p0' SA <br /> 00I <br /> 11 TANK FEE = 550.00/TANK (Prior :o January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 2 TanklY N hY tee fors1986 1987 1988 1989 11990 11991 11992 1993 1994 1995. 1996 <br /> F <br /> Aeach year applicabl eJ XXXX XXXX 5o5.0 v /76 170 S l..! <br /> 11 TANK PENALTY FEES ASSESSED XXXX %XXX 50 <br /> '15012701170-11761 <br /> J 70 J (]y1 O I 5 lei <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25287 <br /> T 3 Tanks, x 556.00 I 1988 through 1990 1991 through 1996 <br /> (Enter amara and year) <br /> -- S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.J. 3(s) <br /> L <br /> 01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) S TANK(s) X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 3 Inscectiors) I TANK 1.0. t(s) <br /> 2 <br /> EI TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimum/FACiLf TY) 5234.00 minirtam S <br /> PI INSTALLATION PLAN CHECX (Plan Review 4 Corutruc:ian Inspections) TANK 1.0. t(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 578.00/hour (8 hours minimum/FACILIT7) = 5624.00 minimum S <br /> RI REPAIR FEE (workp(an Review Z Construction Inspections) TANK I.O. #(s) <br /> E, <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) 3 TANK(s) X 5234.00 = 5 <br /> A <br /> ( TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = SZ34.00 minima S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minim oJFACILIT7) = 5234.00 minimum S <br /> N tRANSFER PEE = 520.00 UNAUTHORIZED RELEASE ViALUATION = S7$_00/hr S <br /> I I I I <br /> S <br /> Cl CCNS)LTATION FEE • S78.00/hr SAMPLING INSPECTION FEE = 978.00/hr S <br /> TOTAL. ME s <br /> FOR OFFICE USE ONLY <br /> SUEEPS +' CCMPUTER d LOC CME DIST CCAE ,UNX)NT RECEIVED CHECK #/CASH RELIVED 3Y )ATE RECEiVE0 <br /> s <br /> y�Erp 23 032 (A 15E0 10-28-93) Q --- Pag,e, 1/�, <br />