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SAN JOAQUIN 2" T PUBLIC HEALTH SERVICES - ENVIRONMENTAL Hk, ll OIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SIJL NAME <br />TANK I.D. #(s) <br />FACILI Y CONTACT NAME <br />T I� _ <br />1988 <br />1989 1990 <br />E <br />FACILITY ADDRESS <br />TOTAL DUE $ gSg, cc) <br />SITE PH E # with AREA CODE <br />to January 1, 1991) = $100.00 <br />U TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />I Cam 'aa -00P3 <br />& <br />R <br />= 5234.00 minimum <br />XXXX <br />A <br />CITY ,1 <br />s. -(-._-'L^ <br />STATE <br />ZIP CODE # of TANKS <br />at SITE <br />A <br />VCx-nWW <br />P <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimm/FACILITY) <br />= $234.00 minimum <br />E <br />P <br />APPLICANT/OILNG NAME <br />C <br />APP CANT CONT CT NAME <br />L <br />Q <br />I <br />T <br />FACILITY PENALTY FEES ASSESSED <br />(If Applicable) <br />XXXX <br />C <br />MAILING ADDRESSAPPLICANT <br />I <br />f <br />P NE Al WITH AREA CODE <br />A <br />7S0 # <br />1 <br />T <br />CITY/ <br />/SS1 ATE <br />ZIP pCODE TYPE of APPLICATION C (ASUK <br />�(raA -{� <br />l <br />4S0 ' (Closure, Installation, etc.) <br />TOTAL <br />C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) <br />TANK I.D. #(s) <br />TANK I.D. #(s) <br />1986 <br />1987 <br />1988 <br />1989 1990 <br />S (pa bb <br />E <br />TOTAL DUE $ gSg, cc) <br />ANNUAL FACILITY FEE (Prior <br />to January 1, 1991) = $100.00 <br />U TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />I <br />R <br />= 5234.00 minimum <br />XXXX <br />E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />f <br />A <br />XXXX <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimm/FACILITY) <br />= $234.00 minimum <br />E <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED <br />(If Applicable) <br />XXXX <br />I XXXX <br />I <br />f <br />1 <br />V <br />TANK FEE _ $50.00/TANK <br />(Prior to January 1,1991) <br />$170/TANK <br />(After <br />January 1, 1991) <br />E <br />At Tanks = <br />1986 <br />19871988 <br />1989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />19951 <br />1996 <br />F <br />(multiply # by fee for <br />%XXX <br />XXXX <br />I <br />/ o <br />E <br />A <br />each year applicable) <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />%XXX <br />E <br />7 <br />L <br />1 <br />STATE SURCHARGE = $56.00 <br />each TANK (Due every 5 years) <br />See California H d S Code, <br />Section 25287 �,,(O <br />T <br />T <br /># Tanks z $56.00 <br />1988 through 1990 <br />7991 <br />through <br />1996 <br />(Enter amount and year) <br />C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) <br />TANK I.D. #(s) <br />TANK I.D. #(s) <br />E <br />P <br />L <br />0 CLOSURE FEE = $78.00/hour (3 hours minimm/TANK) <br />At TANK(s)-4- X 5234.00 = <br />f a-3 y <br />S (pa bb <br />E <br />TOTAL DUE $ gSg, cc) <br />S <br />A <br />U TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />I <br />R <br />= 5234.00 minimum <br />f <br />E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />E <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) - <br />TANK I.D. #(s) <br />E <br />P <br />L <br />Al TANK(s) _ X $234.00 = <br />A <br />N PLAN CHECK FEE = S78.00/hour (8 hours mini=m/FACILITY) I" ,�L = $624.00 minimum <br />S (pa bb <br />R <br />REPAIR FEE (Workp(an Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) <br />Al TANK(s) _ X $234.00 = <br />E <br />CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr <br />E <br />TOTAL DUE $ gSg, cc) <br />A <br />I <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) <br />= 5234.00 minimum <br />f <br />R <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimm/FACILITY) <br />= $234.00 minimum <br />E <br />M <br />TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />E <br />I <br />S <br />C <br />CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr <br />E <br />TOTAL DUE $ gSg, cc) <br />USE ONLY <br />SWEEPS # 1 COMPUTER # I LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK At/CASH I RECEIVED BY I DATE RECEIVED <br />S <br />EN 23 032 (REVISED 10-28-93) <br />mar <br />