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SAN JOAQUIN COUN C HEALTH SERVICES - ENVIRONMENTAL REAL]SON <br /> UND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I Trac Hi h School - Old Trans. De t . Ms . Ann B <br /> T SITE PHONE # with AREA CODE <br /> E FACIL[TYAODRESS ( 209) 831-5032 <br /> 315 E. 11th Street <br /> STATE ZIP CODE # of TANKS <br /> CITY CA 95376 at SITE 1 <br /> A Tracy <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L Tracy Putli <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> Al315 E. 11th Street ( 209) 831-5032 <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CL TY (Closure, ){ea'IMaaE7674X2kK.K <br /> Tracy CA 95376 <br /> TOTAL <br /> 1986 11987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 S <br /> A <br /> D xxxx xxxx 5 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I5170/TANK (After January 1, 1991) <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) <br /> E # Tanks 1966 1987 1968 1989 1990 1991 1992 1993 1994 1995 1996 <br /> = _ <br /> F (multiply # by fee for S <br /> A each year applicable) <br /> C 5 <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx <br /> L <br /> I STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See California H 8 S Code, Seccien 2528 <br /> T1986 through 1990 1991 through 1996 <br /> T # Tanks_ x 556.00 <br /> (Enter amount end year) S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) TANK I.D. #(s) <br /> L # TANK(s)_ X 5234.00 = S 234.00 <br /> 0 CLOSURE FEE - 578.00/hour (3 hours minimum/TANK) <br /> S TANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) <br /> R # TANK(a)_ X 5234.00 = S -0- <br /> E TEMPORARY CLOSURE FEE - S78.00/hour (3 hours minimuo/TANK) <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A5624.00 minimum S -0- <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.I.D. #(s) <br /> E S -0- <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimm/TANK) # TANK(s) X 5234.00 = <br /> A <br /> I TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) = S234.00 mini mum - - <br /> R <br /> PIPING REPAIR FEE 578.00/hour (3 hours minimi = SZ34.00 minimum <br /> m/FACILITY) -D- <br /> MI TRANSFER FEE <br /> = $20.00 UNAUTHORIZED RELEASE EVALUATION - S78.00/hr S _ _ <br /> I <br /> S = 578.00/hr S <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE S <br /> ONLY <br /> USE _ -_::,:-:._. .-�-__-:':__-�-:=-r-:!T.=..!m:::_--__.-._.:::-�:-!_::!!::::!:�_.:::-[__-:!:=:'ii.=.'ii"�:-_:::_'_"i=:;€�!! <br /> FOR OFFICE _...__ ..:....... ...._.......:—.—..::-;:r...-:-,:,-r:�-. _ __ <br /> a SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASX RECEIVED BY OATE RECE V <br /> ii <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />