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SAN JOAOUINb1011TY PUBLIC HEALTH SERVICES - ENVIROMENTAL>JFJILTH DIVSiON <br /> LMDERGROUMD STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILJT SI E NAME C, FAPITY C TCT /__ <br /> I ✓\ � <br /> T <br /> E FACILITY ADDRESSI SITE PN E with AREA CODE <br /> CITE- TATE Zn CCODE M of TANKS <br /> A ` C (!-k J J zU� at SITE <� <br /> P <br /> P APP NT/ LLI G NAME W112 I AP ANT CONTACT NAME <br /> I 6h <br /> C KAILFN ADDRIc- / APPLICANT PHONE N WITH AREA CODE <br /> M �J VJ — C� -e ` '7 -7 Eit CZ <br /> T CITY TE 2 P TYPE of APPLICATION �R-i✓ltivlk�- <br /> .f, ( (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A xxxx %XXX S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx S <br /> I <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> N Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1 1995 1996 <br /> F (multiply # by fee for <br /> A each year app(icable) xxxx xxxx S <br /> C <br /> ITANK PENALTY FEES ASSESSED xxxx xxxx f <br /> L <br /> 1 STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H & S Cale, Section 25287 <br /> T <br /> Y N Tanks x 156.00 1988 through 1990 1991 through 1996 <br /> (Enter ;mount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. N(a) <br /> L <br /> 0 CLOSURE FEE - 578.00/hour (3 hours minimum/TANK) M.TANK(s) x (234.00 = � • <br /> S f <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. N(a) <br /> R <br /> E TEMPORARY CLOSURE FEE _ !78.00/hour (3 hours minimua/TANK) N TANK(s) x 5234.00 - S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.O. N(a) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimus/FACILITY) $624.00 minimus f <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. N(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) N TANK(s) x $234.00 = f <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) • $234.00 minimum f <br /> R <br /> PIPING REPAIR FEE 578.00/hour (3 hours minimm/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr f <br /> I <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ !78.00/hr f <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> !!!!iir:i.=.m:=r_ imirmi!ii:-."- mmm!rV!!me.^.mr!m!!c!r!ma!!-: :!immmenm!.=.a!�o!m::mwnmmm!vn!!mmar_:.!!m!:..:....:.......: :!:9!.=.....:'°'-m=..!.m!m!:��m!e!re�.!!F!=m::..a <br /> ................... <br /> _.._.....:u::::::::::.:c:.:::.:::::::i:INV!.i:ciki!iFilliFlii!:i _ !:�V:.i'=...ate:_:.en.:..:.:...u:.:.::il!Fii.!Niliiii!!INi!!i!ii!li!i5iVV?LVF_!!!Viiilii[:nm_N!r!:dii!FVii!!iilVVlliiT!i!i!Y!!!4!i!in..i_.._:L.nY...^..I..L:.]' -::_- :iWs:� <br /> SWEEPS N COMPUTER N LOC CODE DIST CODE AMWNT RECEIVED CHECK N/CASH RECEIVED BY DATE RECEIVED <br /> M <br /> f N <br /> .T.!OVIVlifliil!!1!1!..VV.".°!11!!m.^.!III!II.^.iVP..^.!NII!Imililii..;-:.gym.i:.!^il. ........ ,!mmi!I!mmmmm!I.P.^.141!Im^IIIIIV!Im!mm0!Immi!i lmViVm7 Lig <br /> iV:::!!iiii V!!i!Ji!iV!V!!Mlui:iiL:!!!ci's!Vri!i'lfiimiii!iJll!!IIILJINIi!IH!!!VtiL'!V!!V!!Oii:Vii!ii.iiiiiim!!iiOmVi!idiiiiNii.N!!!iN!JLBVifiii.VOi.VVIL4G!!:!IgWiliiINCL!!mVaLWVI!!!!IIm61;lOmi!mmiNdimmiipmi!INtlimlmmalliVfli!i!Vtlli!!la8m!V&JVm!i!IVi!iiiilmL4mm <br /> EH 23 032 (REVISED 6-21-93) Page 11 <br />