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SAN :CACUIX =HTY PUBLIC HEALTH SERVICE'S <br />' iRCNMENTAL HEALTH OIVISICH <br />UNDERGaaWTCRAGZ TANK PRCGRAM - FEE WCRXSHEET <br />TOTAL <br />A <br />C 1986 1987 1988 1989 1990 <br />T ANNUAL EAC:LtTY FEE (Prior to January 1, 1991) ■ 5100.00 <br />t 5 <br />TANK FEE ■ SSO.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br />F * Tarks 9 1986 1 1987 1988 1989 11990 1991 1992 1 1993 1 1994 1995 1996 <br />A (multiply a by fee for <br />C each year applicable) 5 <br />I <br />L STATE SL'RC4ARG'c a 556.00 each TANK (Due every 5 years) See California H b S Code, Section 25297 <br />I <br />I Tarks x S56.CO 1986 through 1990 1991 through 1996 <br />T (enter am u-ic and year) <br />S <br />PEX4MENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.O. i(s) <br />C <br />L C; SERE FEE ■ S53.00 per hoar (3 hours miniaLn per TANK) S TANK(s) X 5159.00 ■ S <br />0 <br />S <br />U TE4PCRARY CLOSURE (A one-time permit, for review/inspections) TANK I.O. 5(s) <br />R <br />E TEVCRARY CLOSURE FEE ■ S150.00 each TANK 0 TANK(s) X $150.00 ■ S <br />PLAN CHECK (Install. Plan Review i Construction Inspections) TANK I.O. x(s) <br />PLAN CHECK FEE - $53.00 per hoar (8 hours minimus per Facility) ■ S424.00 mini" S <br />R <br />FAC:LITY SITE NAME <br />FACILITY CCNTACT NAME <br />f <br />S <br />' <br />A <br />I <br />2 <br />PIPING REPAIR FEE ■ S53.00 per hour (3 hoar miniaua per facility ■ S159.00) <br />5 <br />C <br />I <br />FAC:LITY ADORES$ <br />SITE PHONE f with AREA CCOE <br />L <br />I <br />I <br />C:TY <br />STATE <br />CCOE <br />0 of TANKS <br />Y <br />LIP <br />at SITE <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CCHTACT NAME <br />P <br />P <br />L <br />I <br />NAILING ADDRESS <br />APPLICANT PHCNE S WITH AREA CCOE <br />C <br />A <br />V <br />C:TY <br />STATE <br />ZIP CODE [TYPE <br />of APPLICATICH <br />T <br />1 <br />CLOSURE, INSTALLATICN, etc. <br />TOTAL <br />A <br />C 1986 1987 1988 1989 1990 <br />T ANNUAL EAC:LtTY FEE (Prior to January 1, 1991) ■ 5100.00 <br />t 5 <br />TANK FEE ■ SSO.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br />F * Tarks 9 1986 1 1987 1988 1989 11990 1991 1992 1 1993 1 1994 1995 1996 <br />A (multiply a by fee for <br />C each year applicable) 5 <br />I <br />L STATE SL'RC4ARG'c a 556.00 each TANK (Due every 5 years) See California H b S Code, Section 25297 <br />I <br />I Tarks x S56.CO 1986 through 1990 1991 through 1996 <br />T (enter am u-ic and year) <br />S <br />PEX4MENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.O. i(s) <br />C <br />L C; SERE FEE ■ S53.00 per hoar (3 hours miniaLn per TANK) S TANK(s) X 5159.00 ■ S <br />0 <br />S <br />U TE4PCRARY CLOSURE (A one-time permit, for review/inspections) TANK I.O. 5(s) <br />R <br />E TEVCRARY CLOSURE FEE ■ S150.00 each TANK 0 TANK(s) X $150.00 ■ S <br />PLAN CHECK (Install. Plan Review i Construction Inspections) TANK I.O. x(s) <br />PLAN CHECK FEE - $53.00 per hoar (8 hours minimus per Facility) ■ S424.00 mini" S <br />R <br />REPAIR FEE (workplan review i construction inspections) TANK I.O. i(s) <br />P <br />TANK REPAIR FEE ■ $53.00 per hour (3 hours minimWTANK) O TANK(s) X 5159.00 ■ <br />S <br />A <br />I <br />2 <br />PIPING REPAIR FEE ■ S53.00 per hour (3 hoar miniaua per facility ■ S159.00) <br />5 <br />4 TRANSFER FEE ■ $20.00 <br />1 ,.._....,®_� <br />S <br />C CCNSULTATICN FEE ■ $53.00/hr <br />OFFICE USE CNLY <br />------------ <br />m 1 1 <br />E4 23 032 (REV 418/911 ft <br />UMWHCRIZEO RELEASE EVALUATtCN ■ $53.00/hr <br />SAMPLING INSPECTICN FEE a 553.00/hr <br />c <br />Pace 11 <br />f <br />5 <br />TOTAL DUE S <br />'srKaWtwfuAic i v.aYtc7 i <br />