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SAN JOAWII4 PUBLIC HEALTH SERVICES - ENVIRONMENTAL DIVISION <br /> OUND STORAGE TANK PROGRAM - FEE WORKSHEE <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> 1 Yl / r" /U:c/z lee,vi iGf�S <br /> T SITE PHONE # with AREA CODE <br /> E FACILITY DRES _ / <br /> y� Zu// <br /> R STATE ZIP CODE # of TANKS <br /> CITYS� c <br /> A at SITE <br /> P <br /> P APPLICAANNT/BILLING NAME APPLICANT CONTACT NAME <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING AD RESS <br /> " 1 J u <br /> M CA <br /> et <br /> CITY - STATE 21P COO$ TYPE of APPLICATION LI\CI,��e v <br /> / ✓C S G (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> beTachyear <br /> L FACILITY FEE (Prior to January 1, 1991) = $100.00 XXXX XXXX XX%X XXX% XX%X E %XXXXXXXXXXXX <br /> ITY PENALTY FEES ASSESSED (If Applicable) %%XX %%%% X%XX X%XX %XXX S XXXXXXXX%%%%% <br /> FEE = $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> ks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> tiply # by fee for 5 <br /> year applicab(e) X%%X %XXX XXXX XXX% XXXX <br /> PENALTY FEES ASSESSED XXXX XXX% XXXX X%%X XXXX <br /> E SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8nks x 556.00 1988 through 1990 1991 through 1996 <br /> er amount and year) 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE ::t $78.00/hour (3 hours minimum(TANK) # TANK(S)_ X $234.00 = E <br /> 5 <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 minimus <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = 578.00/hour (8 hours mini mum/FACILITY) = S624.00 minimum S <br /> r � n <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 /> TANK RETROFIT REPAIR FEE = $78.00/1hour (3 hours min./FACILITY) 5234.00 minimus <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 f av , U t) <br /> I <br /> S f <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr <br /> TOTAL DUE f (✓ l G'p <br /> FOR OFFICE USE ONLY <br /> ........ .. ._........ :•: ::: :::::n::n::.v::v:.:. ::::: ::u::::::n: :4:illm1111.11:.i..I.1.I..I::.rm.......II....:i....!vL'!!.._......._... m .... <br /> ..n.n.a:.vn..n:. :n.......:..a..=: m: ,:.im...iA.....i.......i..T..........T...iii.....iliiili...:.....li....im". ........: ::-u:n..•m� �:::n:: .• ..:n:�:�u::.:••.: c:� !im!i!iL�N!!!LiiLL!nidli!LVJL::!!klliNiln:L <br /> a <br /> SWEEPS # COMPUTERmAMOUNT ! <br /> # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED Is <br /> m <br /> - ms!msl!rvi!.m!!na.. <br /> :i. ......................................... .....:.....::�:�::�:::�:::::•::::::::::::•:::�::::::�:�::::•::i::!i!i!_!!i!9i;n:,,i!!!n;!i!ii !:::!:r:;1!ill!!ii!!isi!!..;...!i!I;;;:!;!!s!!!i!::::m!I!!::i!!!!s <br /> ........................ ............................::::::::..:...:..:.:...........:........ .!:.:: !!:!:i:!::!isi!:!::::..:I.:..:...:.....:....._.I.I.1..1:...1:11.......:.:.:...:..9 ...._... _:...... ...... ... ... .... . _...._.. ...:.�. � . .. ;;... . <br /> .:..:....:...............::.:.....::::::::!:i ........::..........i.....:.:.........;:.:.:...!:i...::..::.: ..:............... .......... ;.� ....:::•:: ....:: ... ...: : ill ii 911!iI:,LII!::I:Iiiii:ii::v:li::v:v::!:m:::.lull.Iii:III:IIIJI�vL..i::iVm6mmAiiJmaa <br /> m!!i!i!iF!i!!isl:iiiiiil!!!!i!!!!:Iliii!ii!iFiiFF!i!i:.!iliiiiiiiii9ii!!!iiiii!iiiiliiil9!9!!Viil:il:11111:!:!!:::::will:Ii:!::ii !i!!!i!liilii:i!:i!::isisn:i:!ii!iliiis! <br />