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SAN JOAGUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL HDIVSION <br />STORAGE TANK PROGRAM - FEE WORKSHEET <br />SI <br />FACILITY SITE NAME �® <br />FACILITY CONTACT NAME <br />1986 1987 1988 11989 11990 <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br />T <br />A <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />E <br />FACILITY ADDRESS t� { <br />f7(3l1 <br />SITE PHONE # with AREA CODE <br />A <br />Pv <br />CITY <br />/ <br />`ice f�"►d��' <br />STATE <br />ZIP CODE <br /># of TANKS <br />at SITE <br />P <br />L <br />APPLICANT/BILLING NAME <br />2,c� S L�1 i ,a i `o —6- AJ <br />APPLICANT CONTA NAME <br />Kvi3�C7Z i e <br />I <br />C <br />MAIL G ADOR SS <br />-S <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />b . � <br />N <br />T <br />CITY <br />-� <br />STATE <br />e� <br />ZIP CODE <br />r5—? <br />TYPE of APP N <br />(Closure Installatign-Ietc.) <br />wuu. <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) I <br />TANK I.D. #(s) <br />1986 1987 1988 11989 11990 <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br />S <br />A <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />XXXX X)XX S <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />xxxx I xxxx I S <br />I <br />V <br />TANK FEE _ $50.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br />9 Tanks = <br />1986 <br />1987 <br />1988 11989 11990 <br />1991 11992 , 1993 <br />j <br />1994 11995 1996 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) <br />xxxx <br />XXXX <br />S <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />I xxxx <br />xxxx <br />S <br />L <br />I� <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T <br />Y <br /># Tanks x 556.00 1988 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />$ <br />34 <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) I <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANKCs) X 5234.00 = <br />S <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.O. #(s) <br />R <br />El <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />S <br />P` INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum S <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum <br />S��9 <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />S <br />Ni TRANSFER FEE = S20.00 <br />III <br />CONSULTATION FEE = $78.00/hr <br />FOR OFFICE USE ONLY <br />SWEEPS # i COMPUTER # LOC CODE <br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />SAMPLING INSPECTION FEE = S78.00/hr <br />DIST CODE I AMOUNT RECEIVED I CHECK #/CASH <br />Is I <br />EH 23 032 (REVISED 10-28-93) 3 <br />$ <br />5 <br />TOTAL DUE S <br />RECEIVED 3Y I DATE RECEIVED <br />