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SAN JOAQUIN CL, .r PUBLIC HEALTH SERVICES - ENVIROI#ENTAL n-.. -IN DIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S' <br />T <br />FACILITY SITE NAME FACILITY CONTACT,�JJ++AME <br />M�- ^A JL,LSR-r-+ YL7 D/v <br />E <br />AREA CODE <br />FACILITY ADDRESS s M _ S[ PNONEN4,3 <br />g <br />7 y <br />A <br />CITY �7TL <br />-STATE <br />ZIP CODE <br />of KS <br />P <br />T <br />TANK FEE = S50.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />a0 t SITE <br />L <br />APPLICAKT/BILLING NAME? <br />APPLICANT CONTACT NAME <br />I <br />/-j v- J 5 vim` <br />I XXXX XXXX I I <br />C <br />MAILING ADDRESS <br />A PLIGNT PNON # NITN AREA CODE <br />A <br />y .S C <br />p <br />O 6 <br />T <br />CITY I STATE <br />ZIP CODE <br />o LICATION <br /># Tanks x $56.00 1986 through 1990 <br />(Enter amount and year) <br />1991 through 1996 <br />S <br />Closure InstaLtation, etc.) <br />TOTAL <br />A <br />C <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />987 1988 <br />1986 1 1989 1990 <br />XKKK 1000( <br />5 <br />I <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />)00O )0=f <br />V <br />E <br />TANK FEE = S50.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />F <br />A <br />C <br /># Tanks <br />(multiply BTfee for <br />each year app icabte) <br />1 1986 1987 1988 1989 1990 <br />1991 1992 1993 1994 1995 1996 <br />I XXXX XXXX I I <br />S <br />I <br />L <br />TANK PENALTY FEES ASSESSED <br />IXXXX XXIOL <br />S <br />I <br />T <br />STATE SURCHARGE - S56.00 each TANK (Due every 5 years) Sea Catifornia H a S Cade, Section 25287 <br />Y <br /># Tanks x $56.00 1986 through 1990 <br />(Enter amount and year) <br />1991 through 1996 <br />S <br />C <br />L <br />PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) <br />TANK I.D. #(s) <br />0 <br />S <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(S) X SZ34.00 = <br />f <br />U <br />R <br />TEMPORARY CLOSURE (Plan Review a Inspections) <br />TANK I.D. #(s) <br />E <br />TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minima/ FACILITY) <br />5234.00 minimum <br />f <br />` <br />INSTALLATION PLAN CHECK (Plan Review a Construction Inspections) <br />TANK I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE = S78.00/hour (8 hours minimxa/FACILITY) <br />= S624.00 minima <br />$ <br />R <br />E <br />REPAIR FEE (Workplan Review a Construction Inspections) <br />TANK I.D. #(s) <br />P <br />A <br />TANK LINING REPAIR FEE - S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = <br />S <br />I <br />R <br />TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) <br />= S234.00 minimum <br />S <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />S <br />N <br />1 <br />TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION - $78.00/hr <br />$ <br />S <br />C <br />CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br />_ $78.00/hr <br />S <br />TOTAL DUE I $ <br />EH 23 032 (REVISED 10-28-93) Page 11 <br />