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• SAN JOAQUIN A PUBLIC HEALTH SERVICES - ENVIRONMENTAL He DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> Sl FACILITY SITE NAME FACILITY CONTACT NAME <br /> I UN0CAt IA &981 WCAKTHY <br /> E FACILITY ADDRESS SITE PHONE Al with AREA CODE <br /> s -110l FACIFlc Avc 209- 952- 76710 <br /> CITY STATE ZIP CODE9 of TANKS <br /> F -rroc KTOt-I GA 95` 1 at SITE 2 <br /> P APPLICANT/BILLING NAME WlAe APPLICANT CONTACT NAME <br /> L11 UNOCAL_ T101-1 HO EN000M C-Rsc r1 e- <br /> C MAILING ADDRESS APPLICANT PHONE At WITH AREA CODE <br /> A -Ko BROADWAY 9l0 244y <br /> N <br /> T CITYSTATE ZIP CODE TYPE of APPLICATION PIR"-&-TRO FtT <br /> 6AGRAtv(E.NTb GA 95$18 (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 11987 11988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) f100.00 <br /> A xxxx XXXX I S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx S <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 9 Tanks 1986 1987 1988 1989 1990 1991 1992 ( 1993 1994 1995 1996 <br /> F (multiply 9 by fee for <br /> A each year applicable) %)X% %XXX I I I f <br /> C' <br /> 11 <br /> TANK PENALTY FEES ASSESSED I %XXX xxxx I I S <br /> L <br /> 11 STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25287 <br /> T' <br /> Y 9 Tanks z 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. 9(5) <br /> L <br /> 0 CLOSURE FEE - 578.00/hour (3 hours minimm/TANK) 9 TANK(s) X 5234.00 = S <br /> S <br /> UlTEMPORARY CLOSURE (Plan Review 3 Inspections) TANK 1_0. 9(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) $234.00 minimum f <br /> PI INSTALLATION PLAN CHECK (Plan Review 3 Construction Inspections) TANK I.D. 9(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = 4624.00 mini mm $ <br /> RI REPAIR FEE (Workplan Review L Construction Inspections) I TANK I.D. 9(s) kp0 <br /> E, 00 <br /> 307 <br /> ATANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) 9 TANK(s) _ X 5234.00 = S 234 V <br /> [ tANK RETROf IT REPAIR FEE 5$.00/hour C3 hours min./FACILITY) = 5234.00 minimum S IN <br /> R )aDb7 <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = $234.00 minimum S <br /> NI TRANSFER FEE = 520.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr f <br /> TOTAL DUE S 2 � <br /> FOR OFFICE USE ONLY <br /> SWEEPS 9 COMPUTER LOC COOE 0(ST'CODE RECEt VED CHECK 9/CASH RECEIVED 9Y GATE RECEIVED <br /> I I IS I i I <br /> EH 23 032 (REVISED 10-28.93) 3 <br />