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SAN JOADUIN CWw"YY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEw.-:A DIVSION <br /> UNDERGRCUmD STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SI FACILITY SITE NAME FACILITY CONTACT NAME <br /> I <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & Z zC S c/ae - 7" <br /> CITY STATE ZIP CODE # of TANKS / <br /> A L047- cyOz-/o at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C HAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITYUb1CODE I TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 11988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX S <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX X)00( I S <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1 1987 1988 11989 1990 11991 1992 1993 1994 11995 1996 <br /> F (multiply 4-by-fee for <br /> A each year applicable) XXXX XX)IX 5 <br /> I TANK PENALTY FE-ES ASSESSED X)= XXXX I 5 <br /> Ll <br /> STATE SURC4ARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> 7 # Tanks _ z $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <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 minim VTANK) # TANK(s)_ X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspecti ors) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimus/FACILITY) 5234.00 miniR S <br /> P INSTALLATION PLAN EPlanEle�,ew & Constrt'—EInsections) TANK I.D. #(s)LAN PIAN CHECK FEE = 5ours miniRu = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> El' <br /> P TANK LINING REPAIR FEE = S78-00/hour (3 hours miniaam/TANK) # TANK(s) X $234.00 = S <br /> A <br /> Ij TANK RETROFIT REPAIR FEE = 578.00/hour 0 hours min./FACILITY) = 5234.00 minima" S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = SZ34.00 minimun 5 <br /> H TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 878.00/hr S <br /> TOTAL DUE $ 11-2— <br /> FOR <br /> 1-ZFOR OFFICE USE ONLY _ <br /> SWEEPS # COMPUTER # j LOC CODE DIST CODE AMOUNT RECEIVED CHECK X/CASH RECEIVED BY DATE RECEIVED <br /> S I = <br /> EH 23 032 (REVISED 10-28-93) <br />