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SAN JOAQUIN JKY PUBLIC HEALTH SERVICES - ENVIRONMENTAL H TH DIVISION <br />UNOUND STORAGE TANK PROGRAM - FEE WORKSHEETM <br />S1 <br />FACILITY SITE NAME /'400r-4 �—/ �► S I FACILITY CONTACT NAME <br />I <br />'" <br />T <br />E <br />FACILITY ADDRESS SITE PHONE # with AREA CODE <br />"'►rr,� <br />5 <br />O o <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />A <br />�. e> 40 <br />I S234.00 minimum <br />`7 7-416 <br />at SITE <br />P <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />I <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />N <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />(Closure, Installation, etc.) <br />TOTAL <br />1986 1987 1988 1989 1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />A XXXX XXXX I XXXX XXXX XXXX S XXXXXXXXXXXXX <br />C <br />T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX <br />I <br />V TANK FEE = 550.00/TANK (Prior to January 1,1991) S170/TANK (After January 1, 1991) <br />E <br /># Tanks = 11986 1987 1988 1989 1990 1991 1992 1993 1994 1995 .19' <br />F (multiply # y fee for <br />A each year applicable) XXXX XXXX XXXX XXXX XXXX S -5/0 <br />C <br />I TANK PENALTY FEES ASSESSED i XXXX XXXX I XXXX XXXX XXXX S <br />L <br />I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T <br />Y # Tanks x $56.00 1988 through 1990 1991 through 1996 <br />(Enter amount and year)o <br />I/850 S1rE A.,00T It- $ -4-4-00 <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 minimum/TANK) <br /># TANK(s) X $234.00 = <br />5 <br />S <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <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 />I S234.00 minimum <br />S <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) <br />— <br />L <br />A <br />N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br />v.o Ox;z <br />5 >1400 <br />ra n <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />$ <br />M TRANSFER FEE = 520.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr $ <br />I <br />S <br />C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr 5 <br />TOTAL DUE $ G -7 S <br />FOR OFFICE USE ONLY <br />:::::::::-::::::::::::-•:::......::..::::::...... <br />_.. _ _._....._........._.:... _--.........._ <br />SWEEPS # � COMPUTER <br />LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK #/CASH <br />S <br />w gtA,JG6 cv <br />9 <br />RECEIVED BY I DATE RECEIVED <br />