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SAN JOAQUIN CC PUBLIC HEALTH SERVICES - ENVIRONMENTAL HF DIVSION <br /> UML .OAR) STORAGE TANK PROGRAM - FEE WDRKSHEE'. <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & <br /> CITY STATE ZIP CODE # of TANKS <br /> 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 /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A $ <br /> L <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX I XXXX f <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 9 Tanks = 1986 1987 1988 1989 1 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicab(e) S <br /> C <br /> +— <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 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <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 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (PLan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = 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 minimun/FACILITY) = 2624.00 mini mm S <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 = $ <br /> Al I <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = SZ34.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 278.00/hour (3 hours minimum/FACILITY) = 5234.00 mini mm S <br /> M TRANSFER FEE = 420.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 278.00/hr 2 <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED�.y. <br /> EH Z3 032 (REVISED 11-1-92) Page 11 <br />