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SAN JOAOUIN%Y PUBLIC HEALTH SERVICES - ENVIRONMENTA�TH DIVISION
<br /> U OUND STORAGE TANK PROGRAM - FEE WRKSHE
<br /> S FACILITY ,SIIT_E NAME FACILITY CONTACTNAME
<br /> E FACILITYADDR SS SITE PHONE # with AREA CODE
<br /> �/
<br /> CITY / SSL TE ZIP CODE # of TANKS
<br /> A - 7�c2�'"�"1 -Sf�Ir C14 ii at SITE
<br /> P
<br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME
<br /> L 62
<br /> C MAILING ADORES APPLICANT PHONE # WITH AREA CODE
<br /> A
<br /> X t'515
<br /> T CITY STATE ZIP CODE TYPE of APPLICATION [, ='^•-5
<br /> (Closure, Installation, etc.) i
<br /> TOTAL
<br /> 1986 1987 1988 1989 1990
<br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 1100.00
<br /> A %XXX XXX% XXXX XXXX XXXX E XX%X%XXX%XXXX
<br /> C
<br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX %XXX XX%% I XXXX X%XX S XXXXXXX%XXXXX
<br /> I
<br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991)
<br /> E
<br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1 1995 1996
<br /> F (multiply # by fee for
<br /> A each year applicable) X%XX XXXX XXXX XXXX X%%X E
<br /> C
<br /> I TANK PENALTY FEES ASSESSED XX%X XXXX XXXX XXXX X%XX E
<br /> L
<br /> I STATE SURCHARGE = 556.00 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 /> E
<br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s)
<br /> L
<br /> O CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s)_ X 1234.00 = E,
<br /> S
<br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s)
<br /> R
<br /> E TEMPORARY CLOSURE FEE = 178.00/hour (3 hours minimum/FACILITY) 1234.00 minimum E
<br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s)
<br /> L
<br /> A
<br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S
<br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s)
<br /> E
<br /> P TANK LINING REPAIR FEE = 178.00/hour (3 hours mini mun/TANK) # TANK(s) X 22 0 • E
<br /> A
<br /> I TANK RETROFIT REPAIR FEE = 178.00/hour (3 hours min./FACILITY) = $234.00 minimum"" S
<br /> R
<br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = $234.00 mfni#mm n , S
<br /> M TRANSFER FEE 120.00 UNAUTHORIZED RELEASE EVALUATION . 178.00/hr S �V . o 0
<br /> 1
<br /> 1
<br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE - S78.00/hr S
<br /> TOTAL DUE E O G;C)
<br /> FOR OFFICE USE ONLY __ _ _ _
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<br /> �! SWEEPS # COMPUTER # LOC CODE DISTC
<br /> ODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED i!
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