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SAN JOA0l1[N UNDERY IC ORALTN SERVICES - ENVIRONMENTAL <br /> HEALTH •ION D �� <br /> UNDER STORAGE TANK PROGRAM - FEE WORKSHEET <br /> 5 FACILITY SITE NA � FACILITY CONTACT NAME <br /> 1 7.f Dul,C a9alre /iNPt2STATE <br /> 41 -7 <br /> �c /�N/ yf2 <br /> T SITE PHONE # with AREA CODE <br /> E FACILITY ADDRESS <br /> /0858 VEST �i'/R�v �aflD Zo S L� <br /> & ZIP CODE # of TANKS LNVIRUNMENIALH� <br /> CITY 95 36 at SITE 3 PERMIT/SERVI ES <br /> A R/OD.v <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME ����� <br /> L Sziy GO <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A yO 9 Sz'12f:= <br /> S ATE ZIP CODE TYPE of APPLICATION <br /> �9 9s"3>t-� (Closure, Installation, etc.) TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 S <br /> A <br /> C S <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) S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX KXXX S <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) 3 X 5234.00 = 70,-,pO <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours miniff WTANK) # TANK(s)_ X 5234.00 - S <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 S <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 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 mininAm S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S, <br /> I <br /> S <br /> C CONSULTATION FEE $78.00/hr SAMPLING INSPECTION FEE - S78.00/hr S <br /> TOTAL DUE (S �dZ.00 <br /> FOR OFFICE USE ONLY ummNummia. - <br /> :g:---ciuv w viilJa v-rvxTii:vu�•_.....--...... -'Wr.li n'ivuTWi ••L' ._-v-_:_••_�:fiwii'viiii�':::-:iia <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED o <br /> / 44 z <br /> EH 23 032 (REVISED 11-1-92) 0 Pe9e 11 �( ) I } ( D e d-o I <br />