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OjOAOUIN COUNTY PUBLIC HEALTH SEAS <br /> ENVIRONIYIENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM -FEE WORKSHEET <br /> S FACILITY SITE NAMEII FACILITY CONTACT NAME <br /> I b12IGhd6, 5,,q oee,lawaI6 <br /> E FACILITY ADDRESSSITE PHONE # with AREA CODE <br /> Rol, a o /- o?9 y <br /> & CITY �L STATE ZIP CODE # of TANKS <br /> A Jr TUG C <br /> ?S.21.5- at SITE <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L `j C C'e <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A S6 o o/. C _ <br /> T CITY / STATE ZIP CODE TYPE of APPLICATION <br /> S C/L C a .5 (Closure, Installation, etc.) rr l�S V'e C, <br /> TOTAL <br /> A TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> C <br /> T # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> I (multiply €�E—fee for I $ <br /> V each year applicable) XXXX XXXX XXXX XXXX Lxxxx <br /> E $ <br /> TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX <br /> S <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> E # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> amount ount and year) 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minim 5 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minim 5 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minim/TANK) # TANK(s) X $234.00 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 minimum 5 <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minim/FACILITY) = S234.00 minim 5 <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr 5 <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = $78.00/hr 5 <br /> TOTAL DUE Oo� <br /> GI:...ttSE.._QN.L.... _ _ _.__. _ --. _ .._._ _...........___...._._. �--� <br /> SWEEPS <br /> _.#__�COMPUTER L ��W 0=IS1�00 AMOUNY� EEEV(D��HCCASH iiElifED B1��" DA1 RCEIVEIS <br /> ... <br /> M <br /> .� ._.............._....._�.;.;.«:•e:-::.—r.::::�.•—a-�s::....�---�c•:rn:.� ........ara:...s••—•.«x:r.:::::«^: ur_.:m:�..s_......�............. ._•:».r <br /> .�..........._pre.............�.. ......:.^^...:..._r.:::.—:::.«-.—aa—•--:tN <br /> Ilir................................... .._.........__...»..............._....._:r............... ........ .._....... <br /> .._....................._._...................................... .._.«...._ ... __..r..........».»..._................_.........—..«................_......__.._.........._........._._....._. ......_.__....._.».................................... ::::»:::::.:::::::::::�::::::::•::::::::::::::::::::�.:::::�... � <br /> n:r........:.::::::::::::::::::::::::::::::»::::::::::::::•:c—=.:.r.::=:.—._ _•^:r.:u:•�:_.^:::::�W:—.�._.::r. .•ze:: C::::.^.::�M..._^:�::�._«s::.^• ':...«.•�• «:s:__=._...•«::.»..._.::« _ ».............._...........«»»........._.............._......._ <br /> EH 23 046 (Revised 7/10/96) Page 11 <br />