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SAN JOAQUIN alft PUBLIC HEALTH SERVICES - ENVIRONMENTAL HDIVISION UNDL UNO STORAGE TANK PROGRAM - FEE WORKSHEET Es S FACILITY SITE NAME J 2 I y --I � FACILITY CONTACT NAME 1' ..� 2'1",r P� tt 0 r, Ul 1 5 h 9— —i b E FACILITY ADDRESS / ` VY- ,�T SITE PHONE # with AREA CODE a�r� & CITY STATE ZIP CODE ;E*ltOSITE TANKS A —j—C' L6 P P APPLICANT/BILLIN N ME APPLICANT CONTACT NAME L -.L, 0<-a ► 1►�. L Y�.1.1 t� y- -,r . I G A MAILING ADDRESS AREA CODE APPLICANT PHONE # WITH AREA �1 b - ��_ NSTATE T CITY CA ZIP CODE Z r�. TYPE of APPLICATION (Closure, stallatio etc.) wIRl- IZ P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) 1986 1987 1988 1989 1990 TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX A C T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX I V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) E 9 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 F (multiply # by fee for $ A each year applicable) XXXX XXXX XXXX XXXX XXXX C I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ L I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 T Y # Tanks x $56.00 1988 through 1990 1991 through 1996 (Enter amount and year) $ C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) L 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R ETEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ IZ P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) L TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = A N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) E P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ A I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ R PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ M TRANSFER FEE = $20.00 I S C CONSULTATION FEE = $78.00/hr rrw nrry F nqr- nmi Y UNAUTHORIZED RELEASE EVALUATION = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ $ TOTAL DUE I $ iiiiieiEtiiiiiic::::::::: :::::::: :::::::::i:: ........:.:...........................:....._............, SWEEPS # :::::i:: iie:SiiSiciccii::i ;................_................_..»........_......................_. COMPUTER # =::.•w :� ;:-: :::.-� LOC CODE ::;;::� ::::::::::::»,�-.::::c:::::�::::::::_:.:.......;............»..................»......._....»_�.__»...._»;..;..........;......_....»....__...;;....;....__»..;...:::..........................».......... ».....».........................................-................................_...._.»....»_._._:::..._».c.::::::::::.•s:_:»_.:.:::::s ..::::.::_:=._::.:::...»._......_.....__»»»_....::: DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED :::::::::::::::::::::::::::::::-:::.::::::::::;::::¢:s:s::ss:s::st::¢::s:aa[ ............................._...................,....,..;.........:•:_..........................»..................... :_.; ::: t:¢:¢::-:::ass:s _._..._...._...__.._._».»......__.....-..._....._...._.._........._.»...._._._ »_ :¢ss:::a::¢¢ :::sa _a:sa::a :::a:::::-:a:s¢ ::s;-:a:a:- :::=:-:_ _ =:::::::..................:::-::m.::::::.::-� :::::::::::::: 0