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SAM JOAOIIIM COIAI�PUBLIC HEALTH SERVICES - ENVIRONMENTAL NEAODIVSipI <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FAC—IL iY SITE NAME FACILITY CONTACT NAME <br /> o o,2 <br /> " E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> CITY STAT ZIP COD # of TANKS <br /> A <br /> P �Tvc )tom l;k.J �5 Q�.. at SITE <br /> P APPLICANT/BILLING NAME/1 APPLICANT CONTACT NAME <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> T CITY r SATE ZIP CODE , T PLICATION <br /> Losure,'`ilnstal Cation, etc.) �_tVtn1JF-(� <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 1986 1987 1988 1989 1990 <br /> A %XXX xxxx xxxx S <br /> C <br /> FACILITY PENALTY FEES ASSESSED (If AppLicable) XXXx xxxx xxxx S <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply W-Ty-fee for <br /> A each year appu caoie) i %%%X XXX% %%XX i I - <br /> C - <br /> I TANK PENALTY FEES ASSESSED I XXXX xxxx %XXX g <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 x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s)� X $234.00 = <br /> S 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 minimum/FACILITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.O. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = S624.00 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 /> 1 TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> Mf TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr E <br /> i. GuN9uLTATlu.. F.E = aio.Uu/hr SAMPLING INSPECTION FEE = $78.00/hr S <br /> TOTAL DUE E <br /> _Fa ,.Q..F_F.T.GE._US�...QN.l.�z —{ �_:-.— <br /> _ _._ _ <br /> ;it[ ::t= _-ttr- _=y iii;':- -iii=:___—_:t== =mom i[_-:==:_:iR i— ':- ..... <br /> iu <br /> su)E'ps --'Cdiiti'uiER 7! 'COC otiE— 01ST �odE aMcu.M Afffli E��CN�[� 7l/tasN �kt��fVtI��V- -DafE kEcEtv�y <br /> ie <br /> E <br /> EH 23 032 (REVISED 4-29-94) Page 11 <br />