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SAN JOAQUIN CO�—f PUBLIC HEALTH SERVICES - ENVIRONMENTAL HBl-*fH DIVSION UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET S FACILITY SITE NAME FACILITY CONTACT NAME .1 PIEDMONT LUMBER 6 MILL CO. INC. EDWARD SMITH CFO T E FAr 3i 7 l�DFssELEVENTH STREET SITE PHONE # with AREA CODE &— NinKIP //// CITY TRACY STATE ZIP CODE # of TANKS A CA 95376i at SITE ONE P APPLICANT/BILLING NAME APPLICANT CONTACT NAME L C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE A 395 TAYLOR BLVD., SUITE 225 1 6 4 8 M T CITY PLEASANT HILL SLUE Z P CODE TYPE of APPLICATION L,H 9 +523 (Closure, Installation, etc.) CLOSURE TOTAL 986 1988 1989 1990 1 987 ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1A XXXX xxxx XXXX $ C T FACILITY PENALTY FEES ASSESSED (If AppLicabLe) XXXX XXXx xxxx S V TANK FEE = 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) E # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1 1995 1996 F (multiply #T—fee for A each year applicable) XXXX XXXX XXXX $ C I TANK PENALTY FEES ASSESSED XXXX xxxx XXXX $ L I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 T # Tanks I_ x $56.00 1986 through 1990 1991 through 1996 (Enter amount and year) C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) L S CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)ONE x x234.00 = $ 234.00 U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE - S78.00/hour (3 hours minimum/FACILITY) $234.00 minimum Ts - E INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) L A N PLAN CHECK FEE - 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum $ R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) E P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ A 1 TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum $ R PIPING REPAIR FEE = 578.00/hour (3 hours mini mum/FACILITY) = $234.00 minimum $ M 17— TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr $ I S ClCONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr f TOTAL DUE 5 234.00 f..pi....Qi 1.I.. ....U.S.E._ONL1........._.._........ .... .._._...._..__..___..... ...,. _._.........._..............................:.:.....:...........................:rr:r..:........:..............................................................................._......:�.....>c_,v...........................................::......................._...r r•::vv:::::v.....:•::•:::: ..::::::- r::: v:.:..:::: •. ..:L:!lu! : ::.•::::::::c•:: : : . ::: : . v:..;.y:vr..:!:v. ..::-.::::.::::...:::::_: :%;:::• r::..:.::..:...••_ •::-r::r::::::::.. • ._y_r:..u• •::F.••:.:.:c•...............:::Nl M SNEEPS # i COMPUTER if LOC ME D)sY CODE [ AMOUNT RECECV'@0 (NECK #/LASH J RECEIVE=D BY �' 6ATE RECE)VED ja �y. .. .vim:_'er:c:::::::::_.._.._.__._.......y:::ruc......rtvu:v:ne:: ._..$ :r.,,m::errr rrc u¢::v::c::v= ____ _ _ ......................... :::::::::nn:m:r..m:n r::crv:::::::n: ..........ay..., mr_—vv_vm_v:vvc.__..:'F::i::::::..c-:..:' i.._.......r......__..........-......................................_.........__._......._............_................:..................................:......._......_...................................i111..d_...._.....!........................_......_.._.:r...'.:!.:..::c!!......_......... ........_-....._ _ ._...._. __ ..... ...... r...................:.:v:'::r::::::::.;.,......__..::..:::::::::::::.......,... ._vr. EH 23 032 (REVISED 4-29-94) Page TWO