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SAN JOAQUIN C(7TiITY PUBLIC HEALTH SERVICES - ENVIR0NMENTAL WMTH DIVSICM <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> Sl FACILITY SITE NAME FACILITY CONTACT NAME <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> a <br /> T f,J <br /> CITY STATE ZIP CODE # of TANKS / <br /> A at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (CLosure, Installation, etc.) <br /> TOTAL <br /> 1966 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 <br /> C l 5 3oc/ <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) S son <br /> I <br /> V TANK FEE - 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> at Tanks 1986 1987 1988 1989 1199 1991 11992 1993 1994 1995 1996 <br /> F (multiply $ by fee for <br /> A each year applicable) <br /> C <br /> I TANK PENALTY FEES ASSESSED XXW tyR <br /> L <br /> I STATE SURCHARGE - 556.00 each TANK (Due every 5 years) See California H a S Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter t and year) <br /> 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. $(s) <br /> I. <br /> 0 CLOSURE FEE • 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Ptan Review a Inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) $234.00 minima f <br /> P INSTALLATION PLAN CHECK (P(an Review a Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) 5624.00 minima S <br /> R REPAIR FEE (workplan Review a Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ X 5234.00 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minima S <br /> R <br /> PIPING REPAIR FEE 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minim Am S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 378.00/hr I 5 <br /> [ I <br /> S <br /> Cl CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = 578.00/hr 5 <br /> TOTAL DUE 5 <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK S/CASH I RECEIVED BY GATE RECEIVED <br /> 5 <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />