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SAN J0110UIWIT OPPUBLIC HEALTH SERVICES - ENVIRONMENTAWT•IVSION S� � L✓�� <br /> 111IDERGROUM STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SFACILITY SITE NAME q FACILI� CONTACT NJIEi J <br /> E FACILITY ADDRESS SITE PHONE 0 with AREA CODE <br /> t �> wy <br /> CITY STATE ZIP CODE M of TANKS <br /> ATrC�_ C et SiTE <br /> P <br /> P AFPLI!ANT/BILLING NAME APPLICANT CONTACT NAME <br /> L ll� <br /> 1 <br /> C MAILING ADDRESS APPLICANT PHONE R WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) ■ $100.00 <br /> a = <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx : <br /> t <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 11170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply N by fee for <br /> A each year applicable) <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx 5 <br /> L <br /> I STATE SURCHARGE ■ $56.00 each TANK (Due every 5 years) See California N t S Code, Section 25287 <br /> T <br /> T 0 Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. N(a) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minlmtm/TANK) t1 TANK(s) x $234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review It Inspections) TANK I.D. 15(a) 7� <br /> R `d 3 y'7 <br /> E TEMPORARY CLOSURE FEE ■ !78.00/hour (3 hours minimum/TANK) 0 TANK(s) x $234.00 f <br /> P INSTALLATION PLAN CHECK (Plan Review t Construct•lon Inspections)FTANK I.D. #(a) <br /> L <br /> A <br /> N PLAN CHECK FEE ■ 578.00/hour (8 hours minlmuN,FACILITY) = $624.00 minimum 11 <br /> R REPAIR FEE (Workplan Review t Construction Inspections) TANK I.D. Ca) <br /> E <br /> P TANK LiNiNG REPAIR FEE ■ 578.00/hour (3 hours minlou WTANK) 5 TANK(*) x $234.00 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE ■ S78.00/hour (3 hours min./FACILITY) ■ $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE 578.00/hour (3 hours minimum/FACILITY) ■ $234.00 minimum S <br /> M TRANSFER FEE ■ $20.00 UNAUTHORIZED RELEASE EVALUATION ■ 578.00/hr $ <br /> 1 <br /> S <br /> C CONSULTATION FEE $78.00/hr SAMPLING INSPECTION FEE ■ 578.00/hr $ <br /> e TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> :3t!itrt!!i!Fmt!!tu7i"im!�!!pp!! <br /> •'1,!!:1i!�ti!(tHi'r.!&illltnlliiii!nnit tn! a 110MERMEMEm P!r <br /> SWEEPS 0 COMPUTER N LOC CODE DIST CODE AMOUNT RECEIVED CHECK N/CASH RECEIVED BYTill7RECE ED <br /> nfilIBM 9!!n!m . <br /> EN 23 032 (REVISED 11-1-92) Page 09 <br /> �� � <br /> 0 <br />