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SAN J0AQUIN ITY PUBLIC HEALTH SERVICES - ENVIRONMENTAL .TH DIVISION <br /> UNn GROUND STORAGE TANK PROGRAM - FEE WORKSHEET — <br /> S FACILI Y SITE NAME FACILITY CONTACT 4AME <br /> I p FID yDdz <br /> I <br /> E FACILITY 6DRESS CLI <br /> SITE PHONE # with AREA CODE <br /> i ek—J <br /> CITYSTATE ZIP CODE # of TANKS <br /> A GIr-A at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> T 06-Z3R, T 5 TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A )0XX XXXX XXXX XXXX XXXX S XX%XXXXXXX%X% <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXX% XXXX S XX%XXXX1(XXXXX <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 19871988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multip(y # by fee for <br /> A each year applicable) XXXX %XXX XXXXIIXX% %XXX / '' S YA <br /> C 71) V <br /> ITANK PENALTY FEES ASSESSED XXXX XXXX I %XXX XXX% XX%X S D <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> T # Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> 5& 5 <br /> C PERMANENT CLOSURE (Remove( or Authorized Closure-in-Place) TANK I.D. #(a) <br /> — <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 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum S <br /> PINSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.O. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minims Fs <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum $ <br /> MTRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> 1 <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE $a ' <br /> FOR OFFICE USE ONLY _ - � <br /> _—__ <br /> Emil <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> t <br /> 5 <br /> r_.........................................._..............._. .......... .......... _...__ __...___..__._._.__..._.__.. <br /> ....... _— __..._—....___......._... <br />