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SAN JOAQUINPUBLIC HEALTH SERVICES - ENVIROKKENTAL HE+DIVISION <br /> LAND aAo STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME , / FACILITY CONTACT NAME <br /> T Q k6C X73 �( al llina�s & <br /> E FACILITY ADDRESS �, SITE HONE 9 ith AREA CODE <br /> 'f E, YL Sf <br /> CITY C STATEI ZIP CODE k of TANKS <br /> A - at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT XAME <br /> L <br /> I - <br /> C NAILING ADDRESS APPLICANT P40ME * WITH AREA CODE <br /> A <br /> N <br /> T CITY - STATE ZIP CODE TYPE of APPLICATION <br /> (Ctosure, Installation, etc.) <br /> TOTAL <br /> _ 1986 1987 1988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 2100.00 <br /> A _ )0= XXXX �UOr 1'4bO" <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If App(icable) OW <br /> I <br /> V TANK FEE 550.00/TANK (Prior Co Jarivary 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> I Tanks 1986 1987 1 1988 1 1989 11990 ( 1991 11992 11993 1 1994 1995. 1996 <br /> F (muteach ply <br /> S pt fee for <br /> A each year applicable) XXXX <br /> �IL 0' 3 al,� t <br /> I TANK PENa.CN 5 09ALTY FEES ASSESSED XXXX X <br /> L <br /> t STATE SURCHARGE = $56.00 each LANK (Due every 5 years) See California 9 b S Code, Section 25287 <br /> T <br /> T Y Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter ai C and year) 0 <br /> // <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-P(ace) TANK I.D. ANSI <br /> OI CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) 3 TANK(s) d-- X 5234.00 = \ S D� <br /> S <br /> U TEMPORARY CLOSURE (P(an Review 3 Inspections) TANK I.D. S(s) <br /> R <br /> c TEMPORARY CLOSURE FEE = 578.001hour (3 hours minim(-/FACILITY) 5234.00 minim S <br /> PI INSTALLATION PLAN CHECK (Plan Review 3 Construction (nspections)I TANK I.O. 1(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 578.00/hour (8 hours minim.m/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review i Construction Inspections) I TANK I.D. d(s) <br /> E <br /> P TANK IfNIXG REPAIR FEE = 578.00/hour (3 hours minisamVTANK) Y TANK(s) X 5234.OD = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.001hour (3 hours min./FACILITY) = 5234,00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.001hour (3 hours minimu/FACILITY) = 5234.00 minimus S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 378.001hr S <br /> I I I <br /> S <br /> C� CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY �� <br /> SWEEPS S I CCMPUTER LOC CODE GIST CODE AMOUNT RECEIVED CHECX 4/CASH RECEIVED 3Y I DATE RECEIVED 3 <br /> _ s _ <br /> EH Z3 032 (REVISED 10-28-93) • Page 11 <br />