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" SAN JOAOUINPUBLIC HEALTH SERVICES - ENVIRONMENTAL HEA IVSION <br /> UNDE GROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T s— ®2 <br /> E FACILITY ADDRESS r SITE PHONE # with AREA CODE <br /> & ±Z('o Y V A.� G ® Y–a 3 <br /> CITYSTATE 2IP CODE # of TANKS <br /> A at SITE <br /> P <br /> P APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> I C Co CS ®0 AE'L <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> G_( (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 S <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX S <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hair (3 hours minimun/FACILITY) = S234.00 minimum S <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 minimum is <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum S �� L 0 <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> :. ..i» <br /> za.zoo waeesweoweeaewa ze000waswaswoeoowaowoaeoaeas waaos wasxeeesxeexwxewazaxeeosxaoxeees»eaxe.xeaee-zaxaee►�aeaxoeeexw�eeasm,oweo�oaoasxee�eeeaawoazeeaxaxesxaw.xea�eawsxaaxaeeraa,.Maee.Mesxwsa.oeexwxoe <br /> f ?�. ......... 5...»� ' .G�......... ....... ............ .................... .�'.. 7- <br /> ... S3 <br /> alae'aeoe woao i000 woad z'oo zooee o...z»z ieaozooeo zoo woadzao zoaeoieoox00000�uoszoeoo xeoioro�xoa wea x000a.,eee woa..iaoieooe.iaaesao.aawas»aowaeoewoa zamoe,eee 000esmaa.zoo owo.» oxasieeaeiio:zooeizooieoo i0000eiao xa$. <br /> EH 23 032 (REVISED 3-1-93) Paae 11 <br />