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Tanks & Piping <br />SAN JOAQUINLIC <br />HEALTH SERVICES - ENVIRONMENTAL HE�DIVSION <br />UNDE—ROUND STORAGE TANK PROGRAM _ FEE WORKSHEET <br />S FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />I CO Facilit 548 <br />Mohammad A. Taeb <br />T <br />SITE PHONE # with AREA CODE <br />E FAITY ADDRESS <br />7S"t <br />1986 <br />12 Hammer Lane <br />9 478-2723 <br />a <br />CITY <br />S# of TANKS <br />A ockton <br />at SITE 4 <br />P <br />P APPLICANT/BILLING NAME <br />ANT CONTACT NAME <br />L Tait & Associates <br />mas Schoenstein <br />JCODE <br />I <br />CANT PHONE # WITH AREA CODE <br />C MAILING ADDRESS <br />; <br />A 1001 Gal Way,Ste. <br />404 0 680-6800 <br />x. <br />T CITY <br />TYPE of APPLICATION <br />Concord <br />(Closure Installation,etc.) <br />R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br />ES <br />P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X S234.00 = <br />A5 <br />I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum <br />R5 <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />M TRANSFER FEE = $20.00 <br />UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />TOTAL <br />I <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />SAMPLING <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br />5 <br />TOTAL DUE <br />; <br />XXXX <br />XXXX <br />DIST CODE <br />AMOUNT RECEIVED CHECK #/CASH <br />RECEIVED BY DATE RECEIVED <br />SWEEPS # COMPUTER # LOC CODE <br />A <br />$........ .....� ...._..;;..'-::::r»-;.—..n:::n'r....•-'..-»m:::r^s^.r.:—::-•^..:::rm::. <br />•rsrr..:^.:ta:-m^.-::^ <br />�.—.:::;rr: <br />....«....._....»... <br />..........................^-rnt............r.......-rt. <br />�.r^'^ty�+:i;TS:+,:'C:... .. RY.iC'....:S::S.—..S:SSt.•^'^..t................................................. <br />» ...^...... ..... . ........................................_........................................:.......::..............::...........................�:a:._.....«._..« <br />..:;;,.,..,: <br />Cxxxx <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />Ell 23 032 (REVISED 10-28-93) <br />xxxx <br />$ <br />V <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />S170/TANK <br />(After <br />January 1, 1991) <br />)��U:H'�Ot"1� <br />E <br />1987 <br />1988 <br />1989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br /># Tanks = <br />1986 <br />F <br />(ltiply # by fee for <br />mu <br />$ <br />0 <br />A <br />each year applicable) <br />XXXX <br />XXXX <br />C <br />5 <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />L <br />1 <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & <br />S Code, <br />Section 25287 <br />T <br />1988 through 1990 <br />1991 <br />through <br />1996 <br />T <br /># Tanksx $56.00 <br />(Enter unt and year) <br />S <br />-1 <br />C <br />PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) <br />TANK I.D. #(s) <br />SRo bpi 11t <br />I-7 <br />L# <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br />TANK(s) <br />X $234.00 = <br />5 6 <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />RS <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br />- $624.00 <br />- <br />L <br />minimum �p (O l� <br />5 624.00 <br />R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br />ES <br />P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X S234.00 = <br />A5 <br />I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum <br />R5 <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />M TRANSFER FEE = $20.00 <br />UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />5 <br />I <br />S <br />C CONSULTATION FEE = 578.00/hr <br />SAMPLING <br />INSPECTION FEE = 578.00/hr <br />5 <br />TOTAL DUE <br />5 2 <br />FOR OFFICE USE ONLY <br />DIST CODE <br />AMOUNT RECEIVED CHECK #/CASH <br />RECEIVED BY DATE RECEIVED <br />SWEEPS # COMPUTER # LOC CODE <br />$........ .....� ...._..;;..'-::::r»-;.—..n:::n'r....•-'..-»m:::r^s^.r.:—::-•^..:::rm::. <br />•rsrr..:^.:ta:-m^.-::^ <br />�.—.:::;rr: <br />....«....._....»... <br />..........................^-rnt............r.......-rt. <br />�.r^'^ty�+:i;TS:+,:'C:... .. RY.iC'....:S::S.—..S:SSt.•^'^..t................................................. <br />» ...^...... ..... . ........................................_........................................:.......::..............::...........................�:a:._.....«._..« <br />..:;;,.,..,: <br />Ell 23 032 (REVISED 10-28-93) <br />