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SAN JOAOUIN CONN ILIC HEALTH SERVICES - ENVIRONMENTAL NEAT .KION <br /> (NDEbaPITI D STORAGE TANK PROGRAM - FEE WORKSHEET <br /> 4FACILITYIT NAME FACILITY CONTACT NAME <br /> � r L-O 2DDRESS / ITE P E 0 with AREA CODE <br /> C evo eee La " zo", 36 F -7/SQA <br /> STATE ZIP CODE R of TANKS <br /> A CITY O CL ' C ,/ 0 at SITE <br /> a <br /> J APPLICANT CONY T NAM <br /> BILLING NAME <br /> o O h U r r^ 0. <br /> PPLI T PHONE I WITH AREA CODE <br /> DDRESS <br /> a <br /> STATE ZIP CCOE PPLICATION <br /> T 0 (Closure, Installation, etc.) <br /> 141 0 <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> PTANKFEE <br /> FACILITY FEE (Prior to January 1, 1991) = 5100.00 5 <br /> xxxx xxxxPENALTY FEES ASSESSED (If Applicable)= 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> = 1986 1987 1988 1989 1990 1991 19921996 <br /> 0 by fee for S <br /> r applicable) <br /> C S <br /> I TANK PENALTY FEES ASSESSED XxxX XXXX <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H 6 S Code, Section 25287 <br /> T <br /> Y 0 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. 0(s) useT OT <br /> L <br /> 0 CLOSURE FEE - 578.00/hour (3 hours minimum/TANK) 0 TANK(s)_� X 5234.00 = 5 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 6 Inspections) TANK I.D. 0(s) <br /> R — — J <br /> E TEMPORARY CLOSURE FEE 578.00/hour (3 hours mini mim/TANK) 0 TANK(s) X 5234.00 S <br /> PINSTALLATION PLAN CHECK (Plan Review 6 Construction Inspections) TANK I.D. 0(s) <br /> JL <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) 5624.00 mini 5 <br /> R REPAIR FEE (Workplan Review d Construction Inspections) TANK I.D. Nis) <br /> - <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) 0 TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE 578.00/hour (3 hours minin%WFACILITY) = $234.00 minimum 5 <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION - 578.00/hr 5 <br /> I <br /> 5 <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE - 578.00/hr 5 <br /> UV <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY - <br /> SWEEPS 0 COMPUTER 0 LOC CODE DIST CODE I AMOUNT RECEIVED CHECK 0/CASH RECEIVED BY DATE RECEIVED <br /> 3 9 <br /> a 5 = <br /> EH 23 032 (REVISED 11-1-92) Page 11 -..i <br />