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F SAN JOAQUIN Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL WWH DIVSION <br />GROUND STORAGE TANK PROGRAM - FEE WORKSHE <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />I <br /># <br />TOTAL <br />T <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = <br />$234.00 minim <br />1986 <br />1987 <br />1988 <br />E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />& <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />= 578.00/hr <br />$ <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />A <br />$ <br />A <br />at SITE <br />P <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX XXXX <br />I <br />MAK <br />$ <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />V <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />5170/TANK (After <br />N <br />TCITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />1986 <br />1987 <br />1988 1989 <br />1990 <br />(Closure, Installation, etc.) <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /># <br />TOTAL <br />$ <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = <br />$234.00 minim <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />= 578.00/hr <br />$ <br />XXXX <br />XXXX <br />XXXX <br />)( >W <br />$ <br />A <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX XXXX <br />XXXX <br />MAK <br />$ <br />I <br />V <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />5170/TANK (After <br />January 1, 1991) <br />E <br /># Tanks = —3_ <br />1986 <br />1987 <br />1988 1989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />F <br />A <br />(multiply # by fee for <br />each year applicable) <br />XXXX <br />XXXX <br />XXXX XXXX <br />Admor <br />5 <br />C <br />I <br />TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX <br />$ <br />L <br />I <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California <br />H & S Code, <br />Section 25287 <br />T <br />Y <br /># Tanks x $56.00 1988 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />$ <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minim/TANK) <br /># TANK(s) 3 X <br />$234.00 = <br />$ <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = 578.00/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 = 578.00/hour (8 hours minimum/FACILITY) <br />= $624.00 minim <br />$ <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /># <br />TANK(s) X $234.00 = <br />$ <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = <br />$234.00 minim <br />$ <br />PIPING REPAIR FEE = 578.00/hour (3 hours minim/FACILITY) = <br />TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION <br />$234.00 minim <br />= 578.00/hr <br />$ <br />$ <br />CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br />= 578.00/hr <br />$ <br />TOTAL DUE I S 9 <br />Fna nFFTCF USE ONLY <br />EH 23 032 (REVISED 4-6-95) <br />