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SAN JOAQUIN Cowa PUBLIC HEALTH SERVICES ENVIRONMENTAL H . H DIVSION <br />ULMROM STORAGE TANK PR - FEE WORKSHEES <br />S <br />I <br />T <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />L <br />E <br />FACILITY ADDRESS <br />-e <br />SITE PHONE_# with AREA CODE <br />- <br />& <br />TOTAL <br />CLOSURE FEE = $78.00/h (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />S <br />1986 <br />A <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />P <br />® <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br />at SITE <br />P <br />APPLICANT/BI LING NAME <br />APPLICANT CONTACT NAME <br />L <br />Xxxx <br />/ �► <br />XXXX <br />$ <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />N <br />- <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION A16 AJ <br />(Closure, Installation, etc.) <br />C <br />PERMANENT CLOSURE (Removal ofAuthorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />TOTAL <br />CLOSURE FEE = $78.00/h (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />S <br />1986 <br />1987 <br />1988 <br />1989 <br />1990, <br />U <br />TEMPORARY CLOSURE an Review & Inspections) <br />TANK I.D. #(s) <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br />E <br />TEMPORARY CL RE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />Xxxx <br />Xxxx <br />XXXX <br />XXXX <br />$ <br />A <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ <br />I <br />V <br />E <br />TANK FEE = $50.00/TANK <br />(Prior to January 1,1991) <br />$170/TANK <br />(After <br />January <br />1, 1991) <br />I <br />02 <br /># Tanks= <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />F <br />(multiply # Y fee for <br />XXXX <br />xxxx <br />XXXX <br />XXXX <br />! <br />$ <br />A <br />each year applicable) <br />C <br />+ <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ <br />L <br />I <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 <br />years) <br />See California H & S <br />Code, <br />Section <br />25287 <br />T <br />Y <br /># Tanks x $56.00 <br />1988 through <br />1990 <br />1991 through 1996 <br />(Enter amount and year) <br />V <br />$ <br />C <br />PERMANENT CLOSURE (Removal ofAuthorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />0 <br />CLOSURE FEE = $78.00/h (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />S <br />U <br />TEMPORARY CLOSURE an Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CL RE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />$ <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum <br />$ , <br />M TRANSFER FEE _ $2 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br />I <br />S <br />C CONSULTATIO EE _ $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ <br />TOTAL DUE $ ` , <br />FOR OFFICE USE ONLY <br />;sed.. ;-:�= -_ �-�:w:�_..._;:......__:_—•.• ._ . _ ._;_.._...� . . <br />;;..._;.. ....... <br />f:,scz.aEswiai' .;....:— _: .. • .... •�a„i:;,:caiuiu'.__:::.:.-_.Y. _—:tt:..�;. <br />SWEEPS #. (_COMPUTER # I LOC CODE � DIST CODE AMOUNT RECEIVED <br />iF$ <br />91 <br />RECEIVED BY ( DATE RECEIVED <br />