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r. <br />SAN JOAOUINf„QUNTY PUBLIC HEALTH SERVICES - ENVIROUKENTA�LTH DIVSION <br />�ERGROM STORAGE TANK PROGRAM - FEE WORKS <br />'ACILITY SITE NAME <br />{ FACILITY ADDRESS n 6 <br />& G" <br />CITY <br />A&am PC <br />P APPLICANT/BILLING NAME <br />L <br />I <br />C MAILING ADAFFS <br />A <br />NWTI No <br />T CITY R'-? <br />FACILITY CONTACT NAME <br />G CJ <br />SITE PHONE # with AREA CODE <br />W v ol-TtH <br />STATE ZIP CODE # of TANKS <br />X22 at SITE <br />APPLICANT CONTACT NAME <br />S <br />2 APPLICANT PHONE # WITH AREA CODE <br />S TE Z P CODE TYPE of APPLICATION <br />ij (Closure, Installation, etc.) C L.Q SU <br />TOTAL <br />C <br />PERMANENT CLOSURE (Removal or Authorized C(osure-in-Place) <br />TANK I.D. #(s) <br />TANK(s) X $234.00 = <br />S <br />L <br />0) <br />1986 <br />1987 <br />1988 1989 1990 <br />S234.00 minimum <br />= S78.00/hr <br />UR <br />ANNUAL FACILITY FEE (Prior to January <br />1, 1991) = <br />$100.00 <br />�l <br />= S78.00/hr <br />TOTAL DUE <br />S <br />S o <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimus/TANK) <br />S <br />A <br />C <br />T <br />I <br />FACILITY PENALTY FEES ASSESSED (if <br />Applicable) <br />XXXX <br />XXXX <br />S <br />V <br />TANK FEE = S50.00/TANK <br />(Prior <br />to January 1,1991) <br />2170/TANK <br />(After <br />January 1, 1991) <br />E <br /># Tanks = <br />1986 <br />1987 1988 <br />1989 <br />1990 <br />1991 1992 <br />1993 <br />1994 1995 1996 <br />F <br />A <br />(multiply# �yy fee for <br />C <br />each year appticabte)S <br />ITANK <br />PENALTY FEES ASSESSED <br />XXXX <br />XXXX I <br />S <br />L <br />I <br />T <br />FSTATE SURCHARGE = S56.00 each TANK <br />(Due every 5 <br />years) <br />See California H & <br />S Code, <br />Section 25287 <br />Y <br /># Tanks x $56.00 <br />1986 through <br />1990 <br />1991 <br />through <br />1996 <br />I <br />(Enter amount and year) <br />5 <br />C <br />PERMANENT CLOSURE (Removal or Authorized C(osure-in-Place) <br />TANK I.D. #(s) <br />TANK(s) X $234.00 = <br />S <br />L <br />0) <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />S <br />S234.00 minimum <br />= S78.00/hr <br />UR <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />�l <br />= S78.00/hr <br />TOTAL DUE <br />S <br />S o <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimus/TANK) <br /># TANK(s) X 2234.00 = <br />S <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />AlNPLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimus S <br />REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br />TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimus/TANK) # <br />TANK(s) X $234.00 = <br />S <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = <br />2234.00 minimus <br />S <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimus/FACILITY) = <br />TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION <br />S234.00 minimum <br />= S78.00/hr <br />S <br />S <br />CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE <br />= S78.00/hr <br />TOTAL DUE <br />S <br />S o <br />EH 23 032 (REVISED 11-1-92) 0 Page 11 <br />I <br />E <br />