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SAN JOAOUIN Cal <br /> JPUBLIC HEALTH SERVICES - ENVIRONMENTAL HE*DIVSION <br /> UNDE OUND STORAGE TANK PROGRMI - FEE WORKSHEET <br /> r✓ <br /> S FACILITY SITE NAME I FACILITY CONTACT NAME <br /> I _ <br /> E FACILITY ADDRESS PITE PHONE : with AREA CODE <br /> gi 3 - L444 <br /> CITY STATE ZIP CODE of TANKS <br /> Alat SITE <br /> P " <br /> P+ APPLICANT/BILLING NAME I APPLICANT CONTACT NAME <br /> il--�� ` <br /> C; MAILING ADDRESS I APPLICANT PHONE WITH AREA CODE <br /> A! _ ( <br /> N <br /> TI CITY I STATE ZIP CODE I TYPE of APP�, C TION <br /> L J P (Closure, Installation, etc.) <br /> I. TOTAL <br /> A! <br /> 1986 11987 ( 1988 1989 1990 <br /> i ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> p XXXX I XXXX XXXX I 15 <br /> I <br /> Tj FACILITY PENALTY FEES ASSESSED (If Appticaate) I XXXX I XXXX I XXXX I I S <br /> 11 TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> c' <br /> �j Tanks = 198611987 i 1988 11989 11990 i 1991 11992 1993 11994 i 1995 11996 ' <br /> FI (multipty : by fee for <br /> Al each year applicaole) XXXX XXXX i XXXX I I ' I I I ( I S <br /> C' <br /> II TANK PENALTY FEES ASS'ESS'ED XXXX I XXXX I XXXX <br /> L <br /> II STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> YiR Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> Ci PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. :(s) <br /> L, <br /> 01 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) , TANK(s) X 5234.00 = 5 <br /> Si <br /> UI TEMPORARY CLOSURE (Plan Review S Inspections) TANK I.D. -�(s) <br /> I R; <br /> ! <br /> El TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) ( $234.00 minimum S <br /> 1 Pi INSTALLATION PLAN CHECK (Plan Review S Construction Inspections)I TANK I.D. :(s) <br /> L <br /> AI Ou <br /> NI PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S �pZ <br /> i <br /> RI REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. �"(s) <br /> E <br /> P! TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I TANK(s) X 5234.00 = S <br /> A <br /> II TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> Mj TRANSFER FEE = S20.00 I I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I S <br /> S <br /> e <br /> C CONSULTATION FEE = 578.00/hr I I SAMPLING INSPECTION FE=- = $78.00/hr I S <br /> TOTAL DUE S ZL� UO <br /> FOR OFFICE USE ONLY <br /> - - <br /> s: w :_' =.�;mow-.-: -=»::—•:::::::=�—:_ :::-•_ -�—===_—��:W.—:•:::__ _-�=��w_�: �[:_...... a __M:_�.�...........__._.._.....__..._. <br /> _ <br /> SWEEPS COMPUTER LOC CODE ( DIST CODE I AMOUNT RECEIVED CHECK '/CASH <br /> RECE=IVED BY _ DATE RECEIVED _ <br /> �5....... _..._.._....__ i - ___•_ w <br /> ..............__. 1 :.... .. _ _...__._...................._.._.._. .._._._.._. _..._._.. _.r_._......:...... ___._........ <br /> _........_.........................................._......_.._._.._.__......_._._._. _...__..._.__.._._...._.._......__._._.._.__...._ ..................................._._....__..................._.. <br /> __.......... _...._..._...__.............___: .-:::::_::::_::- ...... ........_......:.._._.._::__.._..... _................._......_.._....................................................................................._._.............__. <br /> :H 23 032 (REVISED 4-29-94) <br /> I <br />