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SAN JOAQUIN CC( PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE. DIVSION <br /> UND,r.:ROUMD STORAGE TANK PROGRAM - FEE WORKSHEET - <br /> S FACI TY SITE NAME Mf? ILITY CONTACT NAME _JE jai S Y' J 7 <br /> E FACTLITY ADDRESSTE PHONE # with AREA CODE <br /> CITY C # of TANKSA J Cat SITEPp APPLICANT/BILLING NAMEPLICANTCONCT NAME <br /> L /LI4J '4 /A /� K <br /> L MAILING/ADDRESS A' aJ � ^ S(-+%O 3 APPLICANT PHONE # N7 AREA <br /> A /+ �_/l �[^I (dam 7 <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLI -. -7-,,71?)it <br /> I ,J .,,� <br /> (Closure, ataltationoetc.) � S�4�Q� ; <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXX% XXXX %XX% %X%X S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXX% XXXX XXXX XX%% $ <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 = e_�-- 1986 7987 1988 1989 7990 1997 1992 1993 1994 1995 1 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX %%%% X%XX 7� S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX X%X% XXXX S <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> T # Tanks 856.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) ,:. 5 <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) At TANK(s) X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum S <br /> PI INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) 7 4y <br /> aQA6 <br /> L <br /> A C <br /> N PLAN CHECK FEE = 878.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S�, <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 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = 878.00/hour (3 hours minimum/FACILITY) = 8234.00 minimum S <br /> M TRANSFER FEE = 820.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> S <br /> 1 I <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = $78.00/hr 5 <br /> TOTAL DUE $ 107 <br /> 6 <br /> FOR OFFICE USE ONLY <br /> ....._..._...............:....._...._....................._....___..__..._....._.....___..._............._....................__.._........-.......................... --____ _ __ _ <br /> ..................................................................._.......-....._.............._........_.....__.......................................:.......:.................:........,__�:..:...,......_...::::::::-_:_-:_.—_::::-:--_::::::::::::.—:-::::-:::::::--_:::___::::::.—:..--__-,:..._........... <br /> ............._..__...._............_.........._::_:_......._.._.._._._._..__._....::._:.........,....._..........................._......................................_................._...__...._......._......_....._......................_....................................................._.............._.......,_._...._..... <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> s $ <br /> EH 23 032 (REVISED 4-6-95) <br />