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7FASAN J0AQUIN g&TY PUBLIC HEALTH SERVICES - ENVIRONMENTALTH DIVISION <br /> UNIWOUND STORAGE TANK PROGRAM - FEE WORKSHEEI6 <br /> ILITY SITE NAME FACILITY CONTACT NAME <br /> FACILITY DRESS n SITE PHONE # with AREA CODE <br /> Y STATE ZIP CODE # of TANKS <br /> at SITE <br /> LICANT/ ILLING NAME APPLICANT CONTACT NAME <br /> LING ADDRESS APPLICANT PHONE N WITH AREA CODE <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) 5100.00 1986 1987 1988 1989 1990 <br /> A XXXX XXXX XXXX XXXX KXXX E XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX S XXXXXXXXXXXXX <br /> 1 <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX X%%% %%X% XXXX XXXX E <br /> C <br /> I TANK PENALTY FEES ASSESSED %XXX %%XX XXXX XXXX XXXX E <br /> L <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y # Tanks / X156;1" 1988 through 199�'t ! 1991 through 99 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK LD. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = E <br /> 5 i <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. N(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum S it <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br />. L <br /> A <br /> IIPLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum 5 <br /> ed <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK i.D. #(s) O CTrr'- `T "w <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours mini mum/TANK) # TANK(s) X $234.00kj G 1 CJ' <br /> A <br /> TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum oHiV ;_;f •: S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minium I "ELIC, HEAL r:, <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr $ <br /> 1 <br /> E <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr E <br /> TOTAL DUE E <br /> FOR OFFICE USE ONLY <br /> , ::•:::::::•:::::::::::::::::_,::::.,.—:,::�:::: ::::: ..:•:,:::::::-:::::n,:::::.::::::::::::::::::::::::::,�:::::::,:�� :n,.::::...,._.. .. ..._ ..... ...__......_....._.. <br /> !......................:i.......:.................:._................. !!!.....!ia'!:.:.:...........!.............:.......!.!.........!.I...!!......I:..........:L::m!... .. .......:....,:.o..::..::::: :::,..:.:.:.,::::::.......................,:::.:::::::::::::::::::.:.,::—,,:. .. ._ <br /> I. :.:...........L..R #..v:. .v.::.CIL:LL..:....�....:.!....vAl...dd...n.la.:.�LILI.:Ld....:.1..u.:.._.1...._...L:....J.:.nLnl..6Jn:,,,m,��;,;:;uc::w!Inu!L:.Lu::!!:::uls!::�!:!u1!AiiOilli!iiilii!!film!il0lii!!i0ivi00i!i!iimi!iiiiiii!ill!'!!!If4:ium: ....:: <br /> :1 1 ......:.1111:::1:..0 <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED I� <br /> i <br /> nimm <br /> ........................................._. .............. ................ ........ Ili <br /> ..:. :.......:.:.............................................1:...:.....:.:.11.1.I.I:.......1........:............:...... ........................1_:..:.::............... .. ...............::: .:...........:,rt.:..:.....:........::n.::....:..........n........:..n..:,.. ...... ....... ....... <br /> ..._........._....n.uivn...:a.:..�L.....uu..v....:.:.....1a.1....1V:..Ln....�...:1...IJn.,:L.L:!:Lnmds:::u!!:Ln!unnOdIIIIIAIIIIv:04:!IluLln,l!J!N!n0L00 <br />