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SAIL JOAOIlIN JBLIC HEALTH SERVICES - ENVIRONMENTAL IVSION <br /> STORAGE TANK PROGRAM - FEE WORKSHE <br /> FACILITY CONTACT AME <br /> S FACILITY SITE AME t. <br /> I <br /> T <br /> SITE PHONE. # with AREA CODE <br /> E FACILITY ADDRESS <br /> 076 9)& J J STATE ZIP CODE # of TANKS <br /> CITY <br /> C at SITE <br /> A �7 <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L <br /> 1 � APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITY _ j (Closure, Installation, etc.) <br /> Cc C • C) / --- C_% �---' TOTAL <br /> 1986 1987 11988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 5 <br /> A <br /> C xxxx xxxx 5 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I5170/TANK (After January 1, 1991) <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) <br /> E <br /> # Tanks = -�- 1986 1987 1988 1989 1490 19911992 1993 1994 1995 1996 <br /> F (multiply # by fee for y <br /> A each year applicable) �� �� ' � � <br /> C S <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx <br /> L <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T1986 through 1940 1991 through 1996 <br /> Y # Tanks x 556.00 <br /> (Enter amount and year) $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-place? <br /> TANK I.D. #($) <br /> L # TANK{s) X S234.00 = S <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /> S TANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R S <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimuV/TANK) # TANK(s3 X 5234.00 = <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction inspections) TANK I.D. #(s) <br /> L <br /> A $624.00 minimum S <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/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 = $234.00 minimum $ <br /> PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> I <br /> S = $78.00/hr S <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE <br /> F F I CE USE ONLY <br /> FOR 0 <br /> SWEEPS # COMPUTER # LOC CODE-CODDIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED s <br /> P e 11 Ge > C�l f,r <br /> EH 23 032 (REVISED 11-1-92) <br />