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SAN JOEWIINOCMEMTALPUBLICHEALEALI�'H SERVICES <br /> ON <br /> UNDERGROUND STORAGE TANK PROGRAM -FEE WORKSHEET <br /> ^ FACILITY CONTACT 'lA <br /> S FACILETY S17E NAME LJ.S• •L <br /> T F '� w c LJ SITE�HONE # with AREA CODE <br /> E FACILITY ADDRESS w A -72 <br /> 6 1`�1 `e S AT ZIP ODE # of TANKS <br /> CITY �� 9 5 at SITE 19 <br /> A F� I APPLICANT CONTACT NAM <br /> P APPLICANT/BILLING NAME c II <br /> L �— t F ! C`� x n y G `� APPLICANT PHONE # WITH AREA CODE <br /> 1Fraw <br /> Z�c -��( <br /> C MAILING SITE <br /> ` O p <br /> A ICC) Ic PLICATION <br /> T CITY T TE 21P CODE CZ) i('Q- <br /> 5 �A q5'-1 lasure Installan on, etc.) <br /> CC i<'I'L• 5170/TANK (After January 1, 1991) TOTAL <br /> A TANK FEE = S50.00/TANK (Prior to January 1,1991) <br /> C 1986 1987 1988 1989 1990 1991 1992 1993 17994 1995 1996 <br /> T # Tanks = I $ <br /> 1 (muLtip(y I y�fee for %%%X XXXX XXXX XXXX I XXXX <br /> V each year applicable) I I I I 5 <br /> E TANK PENALTY FEES ASSESSED XXXX XXXX XXXX I XXXX XXXX <br /> S <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California X & S Cade, Section 2528 <br /> T 1986 through 1990 1991 through 1996 <br /> E Enters amount%andbyear) 5 <br /> TANK I.D. #(s) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) % $734.00 = 5 •'� <br /> L c = 578.00/hour (3 hours minimm/TANK) # TANK(s) <br /> O CLOSURE FE. <br /> S TANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review 8 inspections) $ <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 mimmm <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections)I TANK I.D. #(s) <br /> L s <br /> A = 5624.00 minimum <br /> NI PLAN CHECK FE'e = 578.00/hour (8 hours minimm/FACILITY) <br /> TANK I.D. #(s) <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) <br /> E # TANK(s) % 5234.00 = 5 <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimus/TANK) S <br /> A = s234.00 mini mum <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) 5 <br /> R = $234.00 minimus <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimus/FACILITY) <br /> S <br /> M TRANSFER FEE = s20.00 I UNAUTHORIZED RELEASE -EVALUATION = 578.00/hr <br /> 1 = S78.00/hr I 5 <br /> 5 <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION F'cc D G <br /> TOTAL DUE <br /> OMLS .—__.______..____- _—_-,.,_______._.____—_____ _ ii € --V5�e== <br /> �EO(t_D..E_E_I;CE:,US_E .._ --_-_ _ _ __—' s, <br /> =ii_ ';:`::ilii'=;[:': -=ta;---- —. =.--:--- AMbJNIEC{IVED CNECK /CASHT—R{CE1V�D§1 — DAT RECEIVED <br /> H <br /> SuEE7§ # j COMPUTER LOCI ODET—DIST COOS <br /> EH 23 046 (Revised 9/11/96) . Page 11 • <br />