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Page 11 <br />EH 23 032 (REVISED 4-29-94) <br />is 0 <br />SAN jDMIN CotKff PUBLIC HEALTH STORAGE T� ICES - -..r. "+=UNDERGMW va+i• <br />pRoGRM - FEE WORKSHEET <br />FACILITY NAME <br />FACI,15 SITE NAME / C ` <br />�-" Z <br />;i I <br />E <br />C\ <br />ITE PHONE ui with AM CODE <br />8 <br />'.a <br />5_ <br />FACILITY ADDRESS U v \ <br />2 v 3- <br />TE <br />Z <br />CODE <br />0oSITA KS <br />CITY <br />at <br />A <br />P <br />APPLICANT CONTACT NAME <br />P <br />APPLICANT/BILLING NAME S <br />!" �� <br />L <br />APPLICANT PHONE # WITH AREA CODE <br />C <br />MAILING ADDRESSLV rZU <br />M <br />APPLICATION U S �� 17 <br />T <br />STATE <br />CITY C <br />%P CODE <br />S�L� <br />(C1 Ir�Lall8tlon, etc.) <br />C <br />TOTAL <br />1986 1987 1986 1989 1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1491) = S100.00 <br />XXXX XXXX XXXX <br />S <br />A <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX )000( xxxx <br />1 1991) <br />S <br />TANK FEE = 550.00/TANK (Prior t0 January 1 1991) <br />5170/TANK (After January <br />V <br />E <br />1986 1987 1988 11989 1990 <br />1991 1992 1993 1994 1995 1 1996 <br />A <br />= <br /># Yanks fee for <br />eaachtYear X <br />s <br />applicable) <br />S <br />C <br />I <br />TANK PENALTY FEES ASSESSED XXXX X700( XXXX I <br />Set <br />I ' <br />California H & S Code, Section 25287 <br />I <br />STATE SURCHARGE = 556.00 each YANK (Due every 5 years) <br />T <br />$56.00 <br />1986 through 1990 <br />1991 through 1946 <br />Y <br />Tanks x <br />(Enter mount and year) <br />S <br />RMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(S) <br />5234.00 = <br />50 <br />S <br />S78.00/hour (3 hours minia+um/TANK) <br />HLOSURE <br /># TANK(s) X <br />FEE = <br />TANK I.D. #(S) <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />s <br />R <br />LE <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hears minimum/FAC%LSTY) <br />5234.00 mina <br />& C truction Ins ti ) TANK I.D. #(S) 3 K Z Q �' <br />7 - vo <br />P <br />INSTALLATION PLAN CHECK (Plan Review <br />Vu <br />L <br />A <br />578.00/hour (8 hours mini FACILITY) <br />: 4.00 mini <br />S 2 <br />N <br />P CHECK FEE = <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #($) <br />S <br />R <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(S) X $234.00 = <br />S <br />A= <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />5234.00 minimum <br />I <br />R= <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FAC%LITY) <br />S234.00 minimum <br />S <br />UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I <br />S <br />N <br />TRANSFER FEE = 520.00 <br />I <br />S <br />C <br />i <br />CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE <br />: S78.00/hr I TOTAL � <br />5 <br />S ?- <br />Page 11 <br />EH 23 032 (REVISED 4-29-94) <br />is 0 <br />