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PUBLIC HEALTH SERVICES EN�FEE WORKSHEET <br />A SAN JOAaI%N GuDERGstOUND ORAGE TANK P <br />- FACILITY CONTACT NAM <br />ACILIYY SITE NAME <br />SITE PHONE # with AREA CODE <br />FACILITY ADDRESS # of TANKS <br />STATE ZIP CCOE at SITE <br />CITY <br />APPLICANT CONTACT NAME <br />APPLICANT/BILLING NAME <br />APPLICANT PHONE # WITH AREA CODE <br />MAILING ADDRESS <br />STATE ZIP CCOE TYPE of APPLICATIONetc.) <br />(Closure, Irstallat,�on, <br />CITY TOTAL <br />LANK I.D. SCsi <br />P INSTALLATION PLAN CHECK (Ply Review & ConstnN:tion Inspections) 5 <br />L PLAN CHECK FEE = S624.00 minimum <br />A = g78.Q0/hour (8 hours minimum/FACILITY) <br />N <br />TANK J.D. #f s) S <br />R REPAIR FEE (Vorkplan Review & Construction Inspections) # TANK(s) X S234.00 = <br />E 578.00/hour (3 hours minimus/TANK <br />S <br />p TANK LINING REPAIR FEE = = 8234.00 minimum 5 2 3 <br />A S78.00/hour (3 hours min./FACILITY) <br />I TANK RETROFIT REPAIR FE£ _ = 8234.00 minimus <br />R = S78.00/hour (3 hours minimum/FACILITY) <br />PIPING REPAIR FEE S <br />UNAUTHORIZED RELEASE EVALUA <br />N TION = 578.00/hr I <br />TRANSFER FEE = 520.00 S <br />I e 578.00/hr I <br />C CONSULTATION EEE = S78.00/hr I SA14PLING INSPECTION FEE 70TAL DUE S .. <br />=-=- - Page 11 <br />EH 23 032 (REVISED 4-29-94) <br />1986 1987 11988 <br />1989 11990 <br />t 1991) = 5100.00 <br />FEE (Prior to January , <br />XXXX XXXX <br />XXXX 5 <br />ANNUAL FAC%CITY <br />XXXX XXXX <br />�� 5 <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />5170/TANK (After <br />January 1, 1991) <br />FEE = 250.00/TANK (Prior to January 1,1991) <br />1991 11992 1993 1994 1995 1996 <br />TANK <br />- 1986 1987 1988 ' 1989 1990 <br />S <br /># Tanks = fee for XXXX I <br />s (multiplY XXXX XXXX <br />S <br />each year app icable) <br />)CM XXXX I <br />I <br />Y TANK PENALTY FEES ASSESSED XXXX <br />California H &S1Cod�® <br />25287 <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See <br />�through1996 <br />t 1986 through 1990 <br />x 556.00 <br />S <br />T # Tanks <br />(Enter amount and year) <br />Closure -in -Place) <br />TANK #(s) <br />K I.D.I.D <br />S <br />C PERMANENT CLOSURE (Removal or AUthoriled <br />) e <br />#TANK(S)- <br />X S234.00 = r -- <br />(3 <br />01 CLOSURE FEE = 878.00/hour (3 hours minimum/TANK) <br />TANK I.D. #(s) <br />S CttOnS) <br />U TEMPORARY CLOSURE Celan Review & InsPe 5234,00 minimum <br />.. ., „„.,,,,.... 1% hours minimum/FACILITY) <br />5 <br />LANK I.D. SCsi <br />P INSTALLATION PLAN CHECK (Ply Review & ConstnN:tion Inspections) 5 <br />L PLAN CHECK FEE = S624.00 minimum <br />A = g78.Q0/hour (8 hours minimum/FACILITY) <br />N <br />TANK J.D. #f s) S <br />R REPAIR FEE (Vorkplan Review & Construction Inspections) # TANK(s) X S234.00 = <br />E 578.00/hour (3 hours minimus/TANK <br />S <br />p TANK LINING REPAIR FEE = = 8234.00 minimum 5 2 3 <br />A S78.00/hour (3 hours min./FACILITY) <br />I TANK RETROFIT REPAIR FE£ _ = 8234.00 minimus <br />R = S78.00/hour (3 hours minimum/FACILITY) <br />PIPING REPAIR FEE S <br />UNAUTHORIZED RELEASE EVALUA <br />N TION = 578.00/hr I <br />TRANSFER FEE = 520.00 S <br />I e 578.00/hr I <br />C CONSULTATION EEE = S78.00/hr I SA14PLING INSPECTION FEE 70TAL DUE S .. <br />=-=- - Page 11 <br />EH 23 032 (REVISED 4-29-94) <br />