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F SAN JOAQUIN COIARY PUBLIC HEALTH SERVICES - ENVIRO MICIAL NFAIT= DIVSION <br /> I=' `DUMB STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE,�Z G� FACILITY CONTPCT NAME <br /> I <br /> T �I(.L 6P <br /> � <br /> E FACILITY ADDRESS0 SITE PHONE R with AREA CODE <br /> 2Fy 2 <br /> CITY STATE 2 P CODE K of TANKS ' <br /> A 1 ��'�- at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> tM co rni -77bM l <br /> C MAILING ADDRESS 52� APPLICANT PHONE WITH AREA CODE <br /> A T -741, <br /> N <br /> T CITY�Q S ATE ZIP CODE TYPE of APPLICATION <br /> r(iQ oEs no q (Closure, Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 1986 1987 19W 1989 1 1990 <br /> A S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX S <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> Al tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1 1995 1996 <br /> F (multiply N by fee for <br /> A each year applicable) <br /> C 5 <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 6 S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-fn-Place) TANK I.D. #(s) <br /> L <br /> 5 CLOSURE FEE - S78.00/hour (3 hours m(n(mtm/TANK) N TANK(s)�_ X $234.00 = S Z 3 DO <br /> U TEMPORARY CLOSURE (Plan Review b inspections) TANK I.D. #(a) <br /> R <br /> E TEMPORARY CLOSURE FEE - S78.00/hour (3 hours mininxuVTANK) t TANK(s) X $234.00 = S <br /> P INSTALLATION PLAN CHECK (Plan Review E Construction Inspections) TANK I.D. PIS) <br /> L <br /> A <br /> N PLAN CHECK FEE - S78.00/hour (8 hours minim,,YFACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review b Construction Inspections) TANK I.D. M(s) <br /> E <br /> P TANK LINING REPAIR FEE - S78.00/hour (3 hours minium/TANK) R TANK(s) X $234.00 = $ <br /> A - <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour 0 hours min./FACILITY) ! $234.00 minionm S <br /> R <br /> PPPING REPAIR FEE = S78.00/hour (3 hours minirmm/FACILITY) = $234.00 minim m ' S <br /> M I TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr 5 <br /> 5 <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE - S78.00/hr <br /> TOTAL DUE S Z37-P�i/ <br /> FOR OFFICE USE ONLT <br /> r:un_�r:rne::..wa®ai'..:nn:�s _ 33Gm —=— •-••-:•_•.,- <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMWNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> S ' <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />