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SAN J0AQUIN ffPUBLIC HEALTH SERVICES - ENVIRONMENTAL OTH DIVSION <br /> RGROU D STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE {gq{AME . ,FACILITY CONTACT NAME <br /> t, <br /> E FACILITY ADDRESS �/�• / SITE PHONE # with AREA CODE <br /> C)7y / ST TE ZIP a-7 / #of TANKS <br /> A <br /> �/L b 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 /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A xxxx xxxx $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) XXXX XXXx S <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1 1986 1987 1988 1 1989 1990 1991 1992 1993 7994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX (�- (� (:} S �i) <br /> C <br /> I TANK PENALTY FEES ASSESSED XXxx xxxx Fj l� L ") ,'1 f <br /> L <br /> I STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> 50 <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 minimum/TANK) # TANK(s)—L-_ X 5234.00 = <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimm/TANK) # TANK(s) X $234.00 = f <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum f <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 $234.00 = f <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) = 5234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimnVFACILITY) _ $234.00 minimum f <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr f <br /> 1 <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr f <br /> TOTAL DIE $1'7 <br /> FOR OFFICE USE ONLY <br /> ..._:................................._................_.._..............._...............,............. _ ......_ <br /> ........_..........................................._._...................:..:.:..:...............................::--::::::::_:................................................._....................__........._..............................................................._..._....._......_................................_............. ..... <br /> ................._..................................................................................................._.........:c::::::::::em::::::::: .::x......:c-eo:::e:::�:::::::: :e:: ca'-_- <br /> ::::oe:::::::::::_:_..........._.........._....___'__'_'___......._a........_._............._...._.._......................................................... ._ <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASHNo <br /> RECEIVED BY DATE RECEIVED <br /> 5 <br /> .........._......_ _...___::::::::...::.:..........__............=....._.__..... ...... :�-:..��. ...__._._.. ._.._.........,:.-::::�__::::�-:::::::::::::::::::...__......._._.._...............:::::::::—.. ..r_,,,:. .-�� .. . <br /> ....................................._.................._...._........__........._.......................... ........_..::� :::..;......:::_i��a.u:.ai-F:•�!i!_iiy:�:::::::...:v:::::::::::lui'JiiiiiNlk::41!!:i!h!°r�o,_;'.i!lii!!!!!iii!i!!!!!53 <br /> ::......__...........i:_iuciiS:!eP�!cEii!Siv' c:ii_•:isiiuiiiuiiime!61iu r•:....___.__._.__.__.......—isci_-=iivu::.v._i.._:. _..a:.nn:... <br /> EH 23 032 (REVISED 6-21-93) y Page 11 <br />