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SAM JOADUIN IC HEALTH SERVICES - ENVIRONMENTAL HEA�IYSION <br /> I1N0 STORAGE TANK PROGRAM - FEE WORKSHEET <br /> 4I FACILITY SITE NAME FACILITY CONTACT/N-AME, / <br /> 4 v <br /> E FACILITY ADDRESS SITE PHONE 1 With AREA CODE <br /> 4 O / / /Ll,uu ' u 2 - Y(P!�- --2 <br /> CITY c� STATE ZIP CODE s of TANKS <br /> A S1„ cic / Q4 9fZJ Ti at SITE <br /> P <br /> P APPLICANT/BILLING NAME _ APPLICANT CONTACT NAME <br /> sYc <br /> C MAILING ADDRESS APPLICANT PHONE 0 WITH A CObE,-_-, <br /> N <br /> T CITY STATE ZIP CODE PPLICATION <br /> Installation etc.), <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 2100.00 <br /> A 2 <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) X%xx xxxx S <br /> I <br /> V TANK FEE 250.00/TANK (Prior to January 1,1991) 2170/TANK (After January 1, 1991) <br /> E <br /> S Tanks = 1986 1987 1988 1989 1990 1991 1 1992 1993 1994 1 1995 1996 <br /> F (multiply a by fee for <br /> A each year applicable) 2 <br /> C <br /> 1 TANK PENALTY FEES ASSESSED %xxx %XXX 2 <br /> L <br /> 1 STATE SURCHARGE • S56.00 each TANK (Due every 5 years) See Callfornis H 6 S Code, Section 25287 <br /> T <br /> Y k Tanks x 256.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> s <br /> C PERMANENT CLOSURE (Removal or Authorised Closure-in-Place) TANK I.D. 4(a) <br /> L <br /> 0 CLOSURE FEE • 278.00/hour (3 hours minimum/TANK) 0 TANK(s)_ X 2234.00 = S <br /> U TEMPORARY CLOSURE (Plsn Review B Inspections) TANK I.D. 2(s) rynn.a' s,.=, <br /> R <br /> E TEMPORARY CLOSURE FEE • 278.00/hour (3 hours minimum/TANK) <br /> Moe <br /> P INSTALLATION PLAN CHECK (Plan Review d Construction Inspects .....,,>v�. <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = 2624.00 minimum S <br /> R REPAIR FEE (Workplan Review d Construction Inspections) TANK I.D. N(a) <br /> E <br /> P TANK LINING REPAIR FEE • 278.00/hour (3 hours minfmm/TANK) t TANK(s) % 2234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE • 278.00/hour (3 hours min./FACILITY) • 5234.00 minimm S <br /> A <br /> PIPING REPAIR FEE = 278.00/hour (3 hours minimum/FACILITY) - 2234.00 minimum S <br /> MTRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATIO S <br /> Cl CONSULTATION FEE 578.00/hr SAMPLING INSPECTION FEE NQ1711*49 2 <br /> UI;: ,;;(.;;.).JTv rout DUE 2 <br /> 3z ri'✓'cES <br /> PUBLIC HEALn; <br /> ENVIRONMENTAL HEAL? <br /> FOR OFFICE USE ONLY <br /> SWEEPS K COMPUTER X LOC CODE DIST CODE AMOUNT 0.ECEIVEO C NjEASN: RECEIVED BY DATE RECEIVED <br /> :3 <br /> 1 Pa <br /> IL-1-2 <br /> EN 23 032 (REVISED 11-1-92) 6 Page 11 <br />