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SAN JOAOUI IUNTY PUBLIC HEALTH SERVICES - ENVIRONMENT ALTH DIVISION <br />--ERGROUND STORAGE TANK PROGRAM - FEE WORKSHL <br />SI <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />I <br />, �, <br />L <br />T <br />E <br />FACILITY ADDRESS <br />SITE PHONE S�#with AREA CODEI <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />A <br />/ <br />$ ;-7 ed-' <br />C <br />at SITE <br />PAPPLICANT <br />ILLING NAME <br />APPLICANT CONT�T NAME <br />L <br />Sti(c . <br />I <br />C <br />MAKING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />XXXX <br />r <br />$ <br />N <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />(Closure, Installation, etc.) <br />TOTAL <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br />A <br />I <br />S <br />/ <br />$ ;-7 ed-' <br />U <br />TEMPORARY CLOSURE (PLan Review & Inspections) <br />TANK I.D. #(s) <br />A <br />R <br />XXXX <br />XXXX <br />XXXXF-XX <br />E <br />XXXX <br />$ XXXXXXXXXXXXX <br />$ <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ XXXXXXXXXXXXX <br />I <br />V <br />TANK FEE _ $50.00/TANK (Prior to January 1,1991) <br />$170/TANK (After January 1, 1991) <br />E <br /># Tanks = <br />1986 <br />1987 1988 <br />1989 <br />1990 <br />1991 1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />F <br />(multip(y # by fee for <br />A <br />each year applicable) <br />XXXX <br />XXXX XXXX <br />XXXX <br />XXXX <br />$ <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX XXXX <br />XXXX <br />XXXX <br />$ <br />L' <br />I <br />STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T <br />Y <br /># Tanks x $56.00 <br />1988 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />$ <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) <br />TANK I.D. #(s) <br />L <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />A <br />I <br />S <br />/ <br />$ ;-7 ed-' <br />U <br />TEMPORARY CLOSURE (PLan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />$ <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />$ <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum <br />$ <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br />/ <br />$ ;-7 ed-' <br />R <br />PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />$ <br />M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />I <br />S <br />C CONSULTATION FEE _ $78.00/hr I SAMPLING INSPECTION FEE _ $78.00/hr <br />FOR OFFICE USE ONLY <br />$ <br />$ <br />TOTAL DUE $ J �/ 0 <br />SWEEPS # COMPUTER # I LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br />�` �$ <br />