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SAN JOADUIN CO(AITY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UANERGRct= STORAGE TANK PROGRAM - FEE WORKSHEET <br /> 5 FACILITY SITE NAME FACILITY CONTACT NAME <br /> I ? _ <br /> T ; <br /> E FACTLITYjADORESS C- ^ SITE PHONE # with AREA CODE <br /> CITY STATE ZIP CODE # of TANKS <br /> A at SITE <br /> P <br /> Pi 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 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A f <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX X1(XX S <br /> 1 <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> S Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (mitiply # by fee for <br /> A each year applicab(e) S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX S <br /> L <br /> I STATE SURCHARGE - S56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y # Tanks x (56.00 1986 through 1990 1991 through 1996 <br /> (Enter a=unt and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimMTANK) # 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 = 278.00/hour (3 hours minimuNTANK) # TANK(s)_ X $234.00 = S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimus/FACILITY) 5624.00 minimus S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = f <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = 5234.00 mini" S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ <br /> HlTRANSFERFEE = 220.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> l 1 <br /> S <br /> C CONSULTATION FEE _ $78.00/hr 4 SAMPLING INSPECTION FEE _ $78.00/hr f <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER 0 LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASX RECEIVED BY DATE RECEIVED <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />