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C tit--ALIl <br /> SAN JOAOUIN UNDERr �1()NDISTORAGF TANKPROGRA�I - FEE WORKSHEET <br /> FACILITY CONT <br /> FACiLIIY SITE NAME \. <br /> SITE PHONE I with AREA CODE <br /> ff4CILITY ADDRESS \ e <br /> TE Z # of TANKS <br /> at SITE <br /> CITY (� <br /> � \ gppL1,C.ANT CO A T NAME <br /> APPLICANLING N 5 / <br /> APP CANT PHONE WITH <br /> AREA CODE <br /> : MAILING A <br /> 4 ,rr�,TE Z TYPE of APPL <br /> /v'YI�{ (Closure, I st latio etc.) <br /> T CITY TOTAL <br /> 1986 1987 11988 1989 1990 <br /> 00 XXXX XXXX XXXX I S <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) 5100. $ <br /> A XXXX I XXXX xxxx <br /> Clicable) <br /> T FACILITY PENALTY FEES ASSESSED (If App =170/TANK (After January 1, 1991) <br /> IPrior to January 1,1991) <br /> V TANK FEE = S50.00/TANK 1994 1995 <br /> 1 ( <br /> prior <br /> 1986 1987 1988 11989 1990 1991 1992 1993 1 1996 $ <br /> $ Tanks = <br /> F (multiply fee for XXXX XXXX I XXXX I S <br /> A each year app icable) <br /> CXXXX XXXX <br /> I TANK PENALTY FEES ASSESSED I XXXX <br /> L 556.00 each TANK (Due ever 5 years) See California H & S Code, Section 25287 <br /> Y <br /> I STATE SURCHARGE = 1991 through 1996 <br /> T556.00 1986 through 1990 5 <br /> Y 4 Tanks x ear) <br /> (Enter amount and y <br /> TANK I.D. 4(s) <br /> Cl PERMANENT CLOSURE (Removal or Authorized Closure-in Place) X 5234.00 = S <br /> L I TANK(S) <br /> 01 CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) I TANK I.D. #(s) <br /> Sctions) S <br /> UI TEMPORARY CLOSURE (Plan Review Inspections) 523 <br /> E4.00 minimum <br /> R <br /> 7EHPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. ;$(S) S <br /> L = $624.00 minimum <br /> A <br /> s minimum/FACILITY <br /> N' PLAN CHECK FEE = 578.00/hour (8 hour <br /> TANK I.D. #(S) <br /> R REPAIR FEE (Workplan Review & Construction inspections) X 5234.00 = $ <br /> E 4 TANK(s) <br /> P TANK LINING REPAIR FEE = 378.00/hour (3 hours minimum/TANK) _ $234.00 <br /> I TANK RETROFIT REPAIR FEE minimum S <br /> A = S78.00/hour (3 hours min./FACILITY) $ <br /> = 5234.00 minimum <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILI <br /> UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br /> 11 11 11 11 I I 5 <br /> M TRANSFER FEE = $20.00 I $ <br /> ISAMPLING INSPECTION FEE = 578.00/hr <br /> S <br /> C CONSULTATION FEE = 578.00/hr TOTAL DUE $ <br /> .................... �Afi� RECEIVED yi <br /> FOR OFFICE USf <br /> IRCCCIVED- CHECK CASH RECI IVSD B1 <br /> ----------_:::::_:::_::-:::;:-:::sOMPUTE� �•. :.LOC CCOE��—D[S1 COO E• �AMOUN � ai <br /> Page 11 <br /> EH 23 032 (REVISED 4-29-94) <br />