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SAN J01MINAMM PUBLIC HEALTH SERVICES - EMVIRO1WFjffALjftTH DIVSION <br />STORAGE TANK PROGRAM - FEE WORKSHOW <br />S <br />I <br />FAC®I®L`IT®�Y SITE NAME GFACILITY <br />L FIL®rY7V 6-417 <br />CONTACT NAME <br />T <br />4/!v <br />1988 <br />1989 <br />1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />/706? FACILITY ADDRESS %K I T ~ <br />SITE PHONEwith AREA CODE <br />C <br /># TANK(s) X $234.00 = <br />E <br />S <br />XXXX <br />XX)X <br />XXXX <br />XXXX <br />XXXX $ XXXXXXXX <br />A <br />P <br />� <br />ty %� <br />STATE <br />GHQ <br />ZIP CODE <br /># of TANKS <br />at SITE <br />P <br />I <br />APPLICA®NT/BILLING NAME p APPLICANT CONTACT NAME <br />®f es® FA ® 0/7JA-1® <br />C <br />MAILING ADDRESS APPLICANT H ONE # WITH AREA CODE <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION 1 <br />XXXX <br />XXXX <br />XXXX <br />N6;20 <br />(Closure, Installation, etc.) <br />TOTAL <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />O <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />E <br />S <br />XXXX <br />XX)X <br />XXXX <br />XXXX <br />XXXX $ XXXXXXXX <br />A <br />. <br />C <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) <br />$234.00 minimum <br />$ <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX $ XXXXXXXX <br />I <br />V <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br /># Tanks = <br />1987 <br />1988 <br />1989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1445 <br />1996 <br />1997 <br />F <br />(multiply # by fee for <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />S <br />A <br />each year applicable) <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 IS <br />T <br />Y <br /># Tanks x 58.00 <br />1988 through 1990 (S56) <br />1991 through 1996 (S56) <br />1997 <br />SURCHARGE FOR 1997 <br />XXXXXXXX)OXXXX)OO(=XXX)XXX <br />XXXXXXXXXXXXXXXXXXXXXXX <br />S <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />A <br />O <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />E <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) <br />$234.00 minimum <br />$ <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />A <br />H <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br />S <br />R REPAIR FEE (Workplan Review & Construction Inspections) <br />E <br />P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br />A <br />I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />R <br />if IPING REPAIR FEE = 578.00/hour (3 hours minimun/FACILITT) <br />li <br />TRANSFER FEE = $20.00 <br />CONSULTATION FEE = 578.00/hr <br />FOR OFFICE USE ONLY <br />TANK I.D. #(s) <br /># TANK(s) X $234.00 = S <br />$234.00 minimum $ <br />$234.00 minimum S <br />UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br />SAMPLING INSPECTION FEE = 578.00/hr S <br />TOTAL DUE $ <br />EH 23 032 (REVISED 5-27-97) <br />