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SAN JOAOUII 0(TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL 2r4LLTH DIVISION <br /> 1 ;GROUND STORAGE TANK PROGRAM - FEE WORKSHEI <br /> S FACILITY SITE NAME i FACILITY CONTACT NAME <br /> El rACILITY ...DRESS , SITE PHONE # with AREA CODE _ <br /> &� CITY STATEI ZIP CODE i # of TANKS <br /> A ��CC`t: ,-� I�U I ��1�- at SITE -� <br /> P <br /> P APPLICANT/(U LLING NAME APPLIC4T CONTACT NAME <br /> L J c Co N t rc <br /> Cl MAILING ADDRESS I APPLICANT PHONE # WITH AREA CODE <br /> AI -1 1 �T I Sia <br /> N'- <br /> CITY ` STATE ZIP CODE TYPE of APPLICATION <br /> C r ������ (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 11987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX I XXXX I XXXX XXXX XXXX S XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX I XXXX XXXX I XXXX XXXX S XXXXXXXXXXXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 11987 11988 1989 11990 , 1991 11992 1993 11994 1995 1996 <br /> F (multiply # by fee for <br /> AI each year applicable) XXXX XXXX i XXXX I XXXX I XXXX I I I I $ <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX I XXXX XXXX I XXXX I XXXX , I I $ <br /> L. <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1988 through 1990 I 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C� PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X S234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) ! TANK I.D. #(s) <br /> R <br /> EI TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimun/FACILITY) i 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction inspections) I TANK I.D. #(s) <br /> E <br /> P) TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) ; # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> M TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I I S <br /> S� <br /> C CONSULTATION FEE = S78.00/hr ` I SAMPLING INSPECTION FEE = S78.00/hr I $ <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> SWEEPS # I COMPUTER # I LOC CODE I DIST CODE I AMOUNT RECEIVED CHECK #/CASH I RECEIVED BY I DATE RECEIVED <br /> i <br /> --------.L I E <br />