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SAN JOAOl1IN COUNTT . .dLIC HEALTH SERVICES - ENVIRONMENTAL HEALTL /SIGN <br /> + UNDERGRa= STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SI,FACILITY SITE NAME , FACILITY CONTACT NAME <br /> E FACILITY ADDRESS I SITE PHONE # with AREA CODE <br /> & <br /> CITY STATE ZIP CODEof TANKS <br /> A Gp/}T C vl�`Z�`U #a t S, <br /> TE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX XXXX S <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks = 1986 1987 1988 1989 11990 1 1991 11992 1993 1994 11995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX 5 <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX 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 /> Y # Tanks I_ x 556.00 1988 through 1990 1991 through 1996 <br /> I (Enter amount and year) <br /> 00 5 616 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L <br /> OI CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimm/FACILITY) I 5234.00 minimus 5 <br /> P' INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/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 = S78.00/hour (3 hours miniauNFACILITY) = S234.00 minimus S <br /> N TRANSFER FEE = 320.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br /> I <br /> S <br /> C1 CONSULTATION FEE = 378.00/hr SAMPLING INSPECTION FEE = 378.00/hr I S / <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> c (/ <br /> SWEEPS —COMPUTER # LOC GOOF I ots7 CODE I AMOUNT ,RECEIVED CHECK I/CASH RECEIVED aY— I DATE RECEIVED <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />