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SAN J04OUIN OY PUBLIC HEALTH SERVICES - ENVIRONMENTAL ON DIVSION <br /> UNULRGROUND STORAGE TANK PROGRAM - FEE WORKSHEEI <br /> FACILITYSITE NAME FACILITY ACT ono <br /> T /c GP <br /> E FACI ITY ADDRESS SITE PINj # i�th AREA / <br /> ST TE P CODE �(J`' # of fTjANKS <br /> MAW STI <br /> CIT \ at SITE <br /> A s .t) <br /> P <br /> P APPLICANT/BIL G NAME �. APPL GNT CON CT NAME <br /> L <br /> I <br /> C IL IN DDRESS � AIIPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CI Y I ST TE IPCODE, TYPE of APPLICATION <br /> _ (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX E <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX 5 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply >4'�y fee for <br /> A each year applicable) %Xx% XX%X S <br /> C <br /> ITANK PENALTY FEES ASSESSED I XXX% XXX% $ <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> Y # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> mo <br /> (Enter aunt and year) <br /> E <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s)_ 'X $234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY} _ $624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & 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 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum E <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours mi ninAAn/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE = $20.00UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = 578.00/hr $ <br /> TOTAL DUE $ U� <br /> FoRRFFFCE.U.S.E.._RN..L.Y ..._........._.........................._........_._. ...... __......_..._............ ..........._................_......:::::::::::::::::::::::::::::::::::::,:-::::-:::::-:--:::_.—:-:-:::::::-.—::::::::: <br /> __.... :.............................:....................:....:..................................._:.:::::.....::: :::::.:...:........,....................................:...:..::..:::..:...:.:...........................::.... <br /> ................ .:..............................................:........................................................................:....!!!al............................................................!............................................................................................................._......._........ <br /> : :::i : :::::e::::::::::::::::::::::::::::::::t itt::::+:::::::::::::ii:im!e!Rees'c::;;::;:::::!!!!::;::::;:::::is ii!'r::F!:Ftttn:[ee::;;::a::::;:::;: iRG•T.fl::::::.......:Feis:;p::::!!!e!_ <br /> sw€@FS if COMPUTER tt Loc coDC Df5'C CODE AMGUN7 kECECVBD tNECK #/GASH fi ' l7ECEIVEd gY DACE kECECVED <br /> 0 <br /> .. ............ ...................................__............................_$.............._..........._...................._..............__............... ... <br /> .:................................................................. ................_. ....._.._......._...:::::..........�.-::-:-:-................._.._.____..............._....__.......!!! <br /> .... ......,....._...........................:........................... ,........................_..............._ <br /> ....::::::................::.:...:... .--.. .:: ....•' ^ !!:waa::::::::::::::::::;;:!!!!!!!!!!�!!:a:!:[..:.::.:..::anuu,.a:uu.•,�.!r__![!:e.�:::..._!::!:::::::._:!!rnnnnnnu::u:u::::,,w::::::!!::::r;a:;.:......;.;._:.::: <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />