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' 1 <br />SAN JOAOUIN COU' 'MIC HEALTH SERVICES ENVIMMF_11TAL HEAL IVSION <br />UND, -"D STORAGE TANK PROGRAM - FEE WORKSHEET <br />S FACILITY SITE NAME-- <br />I FACILITY CONTACT NAME <br />TEAPPLICANT/BILLING <br />HAL'S ARCO <br />E ADDRESS <br />b <br />A <br />P <br />P NAME <br />L <br />I <br />C MAILING ADDRESS <br />A <br />N <br />T CITY <br />SITE PHONE 0 with AREA CODE <br />STATE ZIP CODE 9 of TANKS <br />at SITE <br />APPLICANT CONTACT NAME <br />APPLICANT PHONE R WITH AREA CODE <br />STATE I ZIP CODE (TYPE of APPLICATION <br />(Closure, Installation, etc.) <br />A <br />C <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />1986 <br />1987 1988 1989 1990 <br />IUTAL <br />T <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable)1000( <br />)000( <br />S <br />V <br />E <br />TANK FEE = S50.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />F <br />A <br />C <br />0 Tanks ' <br />(multiply 0 by fee for <br />each year applicable) <br />1986 1987 1 1988 <br />1989 <br />1990 <br />19911992 <br />1993 1994 1995 <br />1996 <br />S <br />I <br />L <br />TANK PENALTY FEES ASSESSED <br />XXXX XXXX <br />S <br />I <br />T <br />STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />Y <br />0 Tanks x 556.00 <br />(Enter amount and year) <br />1986 through 1990 <br />1991 through 1996 <br />C <br />L <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. 1(s) _ <br />0 <br />S <br />CLOSURE FEE _ $78.00/hour (3 hours miniaua/TANK) <br />8 TANK(s) X $234.00 <br />$ <br />U <br />R <br />TEMPORARY CLOSURE (Plan Review b Inspections) <br />TANK I.D. 0(s) <br />E <br />TEMPORARY CLOSURE FEE a 578.00/hour (3 hours minimum/ FAC ILITY) <br />= S234.00 minimum <br />S <br />P <br />L <br />INSTALLATION PLAN CHECK (Plan Review b Construction Inspections) <br />TANK I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) <br />■ S624.00 minimum <br />$ <br />R <br />E <br />REPAIR FEE (Workplan Review L Construction Inspections) <br />TANK I.D. 0(s) -� <br />P <br />A <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) <br />0 TANK(s) X $234.00 = <br />5 <br />I <br />R <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 ham min./FACILITY) <br />r 5234.00 minimum <br />T <br />PIPING REPAIR FEE _ $78.00/hour (3 hours minimuoVFACILITY) <br />= S234.00 minimum <br />$ <br />M <br />1 <br />TRANSFER FEE = 520.00 IANAUTNORIZED RELEASE EVALUATION = S78.00/hr <br />5 <br />S <br />C <br />CONSULTATION FEE = S78.00/hr LkMPLING INSPECTION FEE <br />= S78.00/hr <br />T <br />TOTAL DUE S <br />FOR OFFICE USE ONLY — <br />wi►�:.�r�wrw�ri.�ir:.Iw w«�r.iw `r`r«rair: ww`n`wil�wi�+ri..li�tMi►fw wit=l�OfMNIM�. ri►rr►=is w�.w ri. osw.•�••i� w. wr: wr • wa-if�:.r�iw wnu wsiN iw �:.i <br />L'S`c�Td� <br />: s <br />arc ams ars wr aarr a�n aarr arr oar anwc man aawn sw aww ann aaaw =on aawlc man aaaw arc WW WX arr WM AX Now WW as W OO MW arc asaaaw aw wwwc man aww>tw aar<ac M Now" sK mvsx man wwr ams ar a*x ams wt <br />EH 23 02 (REVISED 3-1-931 <br />