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SAN JOAQUIN =—TY LIC HEALTH SERVICES - ENVIRONMENTAL '_TIOM <br /> u( STORAGE TANK PROGRAM - FEE WORKSHE <br /> S�j;ACILITY SITE NAME L FACILITY CONTACT NAME <br /> T , `` <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> " X07 <br /> CITY STATE ZIP CODE # of TANKS <br /> Ai � at SITE <br /> LI APPLICANT/B{L LING NAM APPLICANT CONTACT NAME <br /> i a S* C,vv�St <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N it 1-1 C�.� ct vt -72 <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> WAC, i� c�C_ (2c-1 C?S2L-l6 (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) 5100.00 <br /> A S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) X)= XXXX S <br /> i <br /> V TANK FEE = 350.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX 77- S <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) ( # TANK(s) X $234.00 = S <br /> S <br /> UTEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> El TEMPORARY CLOSURE FEE - $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> P INSTALLATION PLAN CHECK (Plan Review $ Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 3624.00 minimum S <br /> R REPAIR FEE (Workplan Review b Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 378.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I 'TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) a 3234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 378.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 378.00/hr S <br /> I <br /> S C 11 W1 <br /> C CONSULTATION F = S .00/ 5'� SAMPLING INSPECTION FEE - S78.00/hr S <br /> V FI/U�C�� - ` TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH I RECEIVED ay I DATE RECEIVED <br /> a <br /> 1'fj ��X2z 3'Z S s <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />