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SAN JOAQUIN Co PUBLIC HEALTH SERVICES - ENVIRONMENTAL He DIVSION fj / <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WRKSNEET <br /> SI FACILITY SITE NAME <br /> I , C.1 I FACILIT.CONTACT NAME <br /> E FACILITY ADDRESS <br /> DOI <br /> ' SITE,PHONE Al vi AREA CODE <br /> CITY - <br /> A / (lY� STATE ZIP CODE a of TANKS <br /> ` [ <br /> C- <br /> P at SITE <br /> P APPLICANT/BILLING NAME <br /> L APPLICANT CONTACT NAME <br /> I <br /> C MAILING ADDRESS <br /> A APPLICANT PHONE 9 WITH AREA CODE <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION GLC.�,J yG <br /> (Closure, Installation, etc.) <br /> Ol TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 19 1987 1988 1989 1990 q8j t o o <br /> CXXXX XXXX loo f O © 95DS <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I XXXX XXX:( D S o__ g9� <br /> V TANK FEE = $50.00/TANK r o 1,1991) $1� TANK <br /> E / (After January 1, 1991) . <br /> Y Tanks = 1986 987., 1988 1989 11990 7991 11992 7993 1994 1995. 1996 <br /> F (multiply i by fee far ✓ l O D <br /> A each year applicable) XXXX )XXX <br /> ` <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX �(] <br /> Lf D� <br /> I STATE SURCHARGE = $36.00 each TANK (Due every 5 years) See California H S S Code, Section 25257 <br /> T •�11 <br /> T R Tanks 556.00 19 Is through 1990 <br /> (Enter amount and year) 7991 through 1996 <br /> C PERMANENT CLOSURE (RCecval or Authorized Closure-in-Place) TANK I.D. x(s) <br /> L <br /> 01 CLOSURE FEE = S78.00/hour (3 hours minimm/TANK) X TANK(s) X 5234.00 = <br /> S Ts <br /> U TEMPORARY CLOSURE (Plan Review S Inspection) TANK 1-D, I(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimae/FACILITY) I SZ34.00 minimID <br /> PI INSTALLATION PLAN CHECK (Plan Review 3 Construction (npections)I TANK 1.0. d(s) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimffVFACILITY) <br /> = 5624.00 minieaao S <br /> R REPAIR FEE (Workp(an Review d Construction Inspection) I TANK J.D. !(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimae/TANK) I X TANK(s) X 5234.00 = <br /> A S <br /> I ,TANK RETROFIT REPAIR FEE = $75.00/hour (3 hours min./FACILITY) - 5234.00 minimae <br /> R - $ <br /> PIPING REPAIR FEE = S78-00/hour (3 hours minimum/FACILITY) = S234.00 minima <br /> S <br /> N TRANSFER FEE $20.00 I UNAUTHORIZED RELEASE EVALUATION = S78_00/hr <br /> I $ <br /> S � <br /> CI CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE = S78.00/hr <br /> $-� <br /> �f/ D <br /> FOR OFFICE USE ONLY �' I � y' TOTAL DUE S <br /> SWEEPS X CCMPUT1 LOC LODE DIST CODE I ANICUNT RECEIVED CHECK d/ASN I RECEIVED By I DATE RECEIVED = <br /> EH 23 032 (REVISED 10-28-93) Page 11 -- _-- _ <br />