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S FACILITY SITE NAME <br />I <br />T <br />E FACILITY ADDRESS <br />& '2072-- F <br />CITY — <br />Ad/1� <br />P <br />P APPLICANT/BILLING NAME <br />L <br />I <br />C MAILING ADDRESS <br />A <br />N <br />T1 CITY <br />PUBLIC HEALTH SERVICES - ENVIRONMENTAL &,H DIVSION <br />STORAGE TANK PROGRAM - FEE WORKSHE , <br />FACILITY C TACT NAME <br />® , <br />SITE PHONE # with AREA CODE <br />STATE ZIP CODE # of TANKS <br />at SITE l <br />APPLICANT CONTACT NAME <br />APPLICANT PHONE # WITH AREA CODE <br />STATE ZIP CODE TYPE of APPLICATION <br />(Closure, Installation, etc.) <br />TOTAL <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />A <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = !100.00 <br />PLAN CHECK FEE = 578.00/hoar (8 hours minimum/FACILITY) = $624.00 minimum S <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />S <br />A <br />S <br />A <br />C <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= S234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= S234.00 minimum <br />S <br />T <br />FACILITY PENALTY FEES ASSESSED (If App(icable) <br />xxxx <br />xxxx <br />TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />S <br />I <br />$ <br />I <br />S <br />c <br />C <br />CONSULTATION F = S .00/ SAMPLING INSPECTION FEE <br />= S78.00/hr <br />S /� <br />TOTAL IX* <br />5 <br />V <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />5170/TANK (After <br />January 1, 1991) <br />E <br />i= <br />N <br />SWEEPS # COMPUTER # LOC CODE DIST CODE I AMOUNT RECEIVED <br />' CHECK #/CASH ( RECEIVED BY <br />DATE RECEIVEDW <br />9 Tanks <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 1991 <br />1992 1993 <br />1994 1995 1996 <br />F <br />(multiply # by fee for <br />S <br />A <br />each year applicable) <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />xxxx <br />XXXX <br />S <br />L <br />I <br />STATE SURCHARGE = S56.00 each TANK (Due every 5 years) <br />See California H & S Code, <br />Section 25287 <br />T <br />Y <br /># Tanks x $56.00 1986 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />S <br />C <br />PERMANENT CLOSURE (Removal or Authorizes! Closure -in -Place) <br />TANK H.D. #(s) <br />L <br />0 <br />CLOSURE FEE = 578.00/hoar (3 hours minimum/TANK) <br /># TANK(s) X <br />$234.00 = <br />$ <br />S <br />U <br />TEMPORARY CLOSURE Celan Review & Inspecti) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X <br />$234.00 = <br />S <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE = 578.00/hoar (8 hours minimum/FACILITY) = $624.00 minimum S <br />EH 23 032 (REVISED 11-1-92) Page 11 <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= S234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= S234.00 minimum <br />S <br />N <br />TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />S <br />I <br />S <br />c <br />C <br />CONSULTATION F = S .00/ SAMPLING INSPECTION FEE <br />= S78.00/hr <br />S /� <br />TOTAL IX* <br />5 <br />FOR OFFICE USE ONLY <br />MUM <br />i= <br />N <br />SWEEPS # COMPUTER # LOC CODE DIST CODE I AMOUNT RECEIVED <br />' CHECK #/CASH ( RECEIVED BY <br />DATE RECEIVEDW <br />s <br />EH 23 032 (REVISED 11-1-92) Page 11 <br />