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SAN JOAQUIN C(TRITY PUBLIC HEALTH SERVICES - ENVIROWEMTAL V-'LTH DIVSION <br /> I RGWJ D STORAGE TANK PROGRAM - FEE WORKSHE <br /> 5 FACILITY SITE NAME FACILITY CONTACT NAME <br /> I <br /> 7 <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> CITY STATE ZIP CODE # of TANKS <br /> A et 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 /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 1986 1987 1988 1989 1990 <br /> A X)= XXXX XXXX S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX xxxx S <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After Janwary 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply I y�fee for <br /> A each year applicable) XXXX XXXX I XXXX S <br /> C <br /> I TANK PENALTY FEES ASSESSED JO(XX )OOIX XXXX 5 <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> T # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minima/TANK) # TANK(s) X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspection) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimlm/FACILITY) 5234.00 minimum <br /> S <br /> PLINSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> NHECK FEE = 578.00/hour (8 hours mini ntn/FACILITY) = 5624.00 minimum g <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours Ninimm/FACILITY) = 5234.00 minimum 5 <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 5 <br /> I <br /> 'C[CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr 5 <br /> TOTAL DUE S <br /> swE€os-# toM6JgER-#�LOL`�b8 1rC DE'TA6iaiA9�'RECEIVED�CHEC�#/ r—RECI:TvEd 9i'—�'-oA7E R'E @'tv'Eti M <br /> EH 23 032 (REVISED 4-29-94) Page 11 <br />