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` r SAN JOAOUINPUBLIC HEALTH SERVICES - ENVIRONMENTAL N 40DIVSION <br />UNO GROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S� FACILITY SITE NAME I FACILITY CONTACT NAME <br />TI V >J <br />E <br />FACILITY ADDRESS SITE PHONE with AREA CODE <br />1986 <br />2.'i © j vl- (vl4,v2-z . { 1 L -k-1 ' Zo i H "13 - n 3 3 '1 <br />& <br />CITY <br />STATE <br />ZIP CODE o I A of TANKS <br />SITE <br />Al <br />r <br />S.TGG.aG. OTa <br />�-A <br />yj2 J' 1 at <br />P. <br />P+ <br />APPLICANT/BILLING NAME <br />I APPLICANT CONTACT NAME <br />LI <br />XXXX <br />C1 <br />MAILING ADDRESS <br />I APPLICANT PHONE : WITH AREA CODE <br />A <br />I XXXX ` <br />XXXX I <br />N <br />TI <br />CITY <br />STATE <br />ZIP CODE <br />I TYPE of APPLICATION <br />S170/TANK <br />I <br />January <br />(Closure, lnstaltation, etc.) <br />j <br />1986 <br />1987 11988 <br />1989 1990 <br />ANNUAL FACILITY FE=_ (Prior <br />to January 1, 1991) = S100.00 <br />A <br />XXXX <br />XXXX I <br />XXXX ( <br />` S <br />Tj FACILITY PENALTY FEES ASSESSED (if Ap 0 =0te) <br />I XXXX ` <br />XXXX I <br />XXXX I <br />I S <br />It- <br />tVI TANK FEE_ = S50.00/TANK <br />V1 <br />(Prior <br />to January 1,1991) <br />S170/TANK <br />(After <br />January <br />1, 1991) <br />-i 9 Tanks= <br />1486 <br />11987 i 1988 11989 i <br />1990 1 1991 11992 <br />1993 <br />1994 i <br />1995 ! 1996 I <br />FI (multiply A by fee for <br />At each year applicaole) <br />XXXX <br />I XXXX i XXXX <br />S <br />!I TANK PENALTY FEES ASSESSED <br />XXXX <br />I XXXX I XXXX I i <br />I j <br />I <br />( 5 <br />I1 STATE SURCHARGE = $56.00 <br />each TANK <br />(Due every 5 years) <br />See California H b S <br />Code, <br />Section <br />25287 <br />T' <br />TI 1 Tanks x S56.00 <br />( <br />1988 through 1990 <br />' 1941 through 1996 <br />1 <br />(Enter amount and year) I I I s <br />Ci PERMANENT CLOSURE (Removal, or AutnoriZed Closure-in-Ptace) I TANK I.D. =(S) <br />L. X 5234.00 <br />01 CLOSURE F=_ = 578.00/hour (3 hours minimum/TANK) ! A TANKS) <br />s' <br />UI TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. ^(S) <br />R' <br />El TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum <br />PI INSTALLATION PLAN CHECK (Plan Review & Construction insr_c:ions)` TANK I.D. WOW <br />L <br />A <br />N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br />RI REPAIR FEE (Workplan Review & Construction Inspections) <br />F <br />P! TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br />A <br />I;, TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />5 <br />S <br />S <br />TANK I.D. $(S) <br />�'. TANK(s) X 5234.00 = S <br />= 5234.00 minimum I S <br />= 5234.00 minimum I S <br />M, TRANSFER FEE = S20.00 I ( UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />S <br />C CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION Fac = S78.00/hr <br />TOTAL DUE <br />FOR OFFICE USE ONLY <br />SWEEPS I COMPUTER ( LOC CODE I DIST CODE I AMOUNT RECEIVED i CHECK R/CASH ! RECEIVED 3Y <br />S ! <br />EH 23 032 (REVISED 4-29-94) <br />TOTAL <br />S <br />5 �ZJ-4 <br />DATE RECEIVED <br />