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SAW JOAOUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL H0 DIVSION <br /> r OUNO STORAGE TANK PROGRAM - FEE UORKSHEET <br /> S FACILITY SIT NAME FACILITY CONTACT NAME �! <br /> I " ! ry Q fT/ G!'tN <br /> T <br /> ae <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 8 5. J C �C ►� rZ67 <br /> CITY STATE ZIP CODE # of TANKS <br /> rpt � ,. !� at SITE <br /> P <br /> P APPLICANT/BILLING NAME 1/ APPLICANT CONTACT NAME <br /> L �,/a / r to (SIC <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION AVSv✓t <br /> `{ )rS (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1994 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXx $ <br /> I <br /> V TANK FEE = 550.00/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 # by fee for <br /> A each year applicable) $ <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx S <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & 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 u <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) '1-- X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = 5 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum 5 <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> 1 <br /> S - <br /> C CO�ULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = $78,00/hr S <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY <br /> «... ........................................................_........,...............«_...,...:„«...,...,.........:..::....................__...._._x ., w� ...... <br /> ... . . ..................................:......:..._......... .,....,.....,...........»»......_..,......-:s::;,�::::�::::x::::::::::::::...:-.::.:.:._:..:....:::::� : t�sxr�r=.•i�::.,r�:��s�saaavu��s::::.�_.�:s>spa:::,::::::�s:�:.:;:.>:;;::::::,x <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> Tiz <br /> b <br /> i <br /> 53 �_ <br /> ZG <br /> u.....,..............,..�......................_.._._.......:u....i..._..........._......`..-..-...i..uv........,.:»._................_..................a[u,..[....................»..o.»...:.».»...»............s,.s..s...,,.......,.._.,-.-............��.......�.._.....__.._..._�.....,...........�.......c.....v........,.:v:.•.:..iyJ/, <br /> •4s'I�.. L:::: . <br /> EH 23 032 (REVISED 11-1-92) z! / :::a:::::n:rznF:.:ahs:::::::s•.•...-.:.•.s.«....._....—».-«:.•.r..•..-...,-..«._,..._....... <br /> l <br />