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SAN 40"IN G .Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL h,d.H DIVSION <br /> IADtRGRORD STORAGE TANK PROGRAM - FEE NORKSHEET <br /> Y FACIIISITE NAM , FACI T ONTA NAME <br /> rfr L+TY <br /> E FACITY <br /> ADDRESS SITE PHONE with AREA CODE <br /> r Nnn <br /> CI SjAiE ZIP?C &^5 # of TANKS / <br /> A (\/q�- U/ at SITE <br /> P <br /> PAPPLICANT/ LING NAME APP CANT CON TA N <br /> C SUb�r� l�orKs �or s <br /> A M (LING ADOREZS �r APPLICANT PHONE # V1TH AREA Cjlp�Z <br /> 9 U�FIJ� <br /> T CI S ATE ZIp C9DE TYPE of APPLICATION <br /> u/=-4K0n/Z (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1 1989 1990 <br /> A ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 jo& f ZOQ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %%X% <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # bye <br /> for <br /> A each year applicable) 5� rz- /� <br /> C <br /> I TANK PENALTY FEES ASSESSED X%%X XXXX A/ f <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y # Tanks X $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 478.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimm/TANK) # TANK(s) X $234.00 = f <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> N1 <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY <br /> SWEEPS # C LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />