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SAN JOAQUIN CC PUBLIC HEALTH SERVICES - ENVIRONMENTAL Ht I DIVSION <br />UNUe GROUND STORAGE TANK PROGRAM - FEE WORKSHEET — <br />S <br />FACILITY SITE NAME <br />1986 1987 1988 1989 1990 <br />X100( )000( <br />F CILITY CONTACT NAME <br />I <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX XXXX <br />C�iL <br />T <br />P <br />5170/TANK (After January 1, 1991) <br />�� LIS <br />E <br />FArlL DRESS <br />SSE PHONE # with AREA CODE <br />1991 1992 1993 1994 1995 1996 <br />1 <br />en <br />L <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />I XXXX XXXX <br />CITY <br />STATE KS <br />ZIP CODE1 <br />A <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />U1 ��6 at SITE 7 <br />PN <br /># Tanks x $56.00 <br />(Enter amount and year) <br />1986 through 1990 <br />P <br />APPLICANT/BILLING NAME <br />561 Z5b <br />APPLICANT CONTACT NAME <br />L <br />C7VN\PC <br />PcN0bKS6N <br />I <br />C <br />MAILING ADDRESS <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />26H 20 <br />S <br />o 8zo 3z <br />T <br />CI YkAm <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />STATE <br />4ysCTE <br />InstalLation, <br />TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minim=/FACILITY) <br />alJ <br />S <br />(CLosureat. <br />TOTAL <br />A <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />1986 1987 1988 1989 1990 <br />X100( )000( <br />S <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX XXXX <br />S <br />V <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br />F <br />A <br /># Tanks = <br />(multiply if�fee for <br />each year applicable) <br />1986 1987 1988 1989 1990 <br />1991 1992 1993 1994 1995 1996 <br />XXXX XXXX <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />I XXXX XXXX <br />S <br />I <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />Y <br /># Tanks x $56.00 <br />(Enter amount and year) <br />1986 through 1990 <br />1991 through 1996 <br />561 Z5b <br />S l 12.00 <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s)_I_ X $234.00 = <br />S 2-3 0 <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minim=/FACILITY) <br />$234.00 minimum <br />S <br />PINSTALLATION <br />PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br />= $624.00 minimum <br />S <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE - 578.00/hour (3 hours minim=/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= $234.00 mini mm <br />5 <br />R <br />PIPING REPAIR FEE 578.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum <br />S <br />M <br />TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr11 <br />5 <br />5 <br />C1 <br />CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br />= 578.00/hr <br />S <br />TOTAL DUE 5 <br />EH 23 032 (REVISED 10-28-93) Page 11 <br />