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SAN JOIN COUI&LIC HEALTH SERVICES - ENVIRONMENTAL NEAL&VSION <br />IIIDERGROl10 STORAGE TANK PROGRAM - FEE WORKSHEET <br />S FACILITY AOU <br />TOTAL <br />SITE NAME <br />FACILITY CONTACT NAME <br />T <br />+` '` <br />/1"I I' �'� I N R 0 <br />E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />3 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />$ <br />A <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS PERMIT/SERV-IC' <br />P <br />r. ' - <br />� <br />at SITE <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT N <br />I <br />C <br />MLING RESS <br />APPLICANT PHONE # WITH AREA CODE <br />T <br />T <br />C�ITY <br />STATE <br />21P CODE TYPE of APPLICATION <br />� `?0;1i (Closure, Installation, etc.) <br />TOTAL <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK T.D. #(a) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br /># TANK(s) X $234.00 = <br />3 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />$ <br />$ <br />U <br />TEMPORARY CLOSURE (Plan Review & inspections) <br />TANK I.D. #(s) <br />R <br />$ <br />E <br />TEMPORARY CLOSURE FEE _ $78I..00/hour (3 hours minimun/TANK)# <br />S <br />A <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (if Applicable) <br />XXXX <br />XXXX <br />= <br />I <br />V <br />TANK FEE _ $50.00/TANK (Prior to January 1,1991) <br />$170/TANK (After January 1, 1991) <br />E <br /># Tanks <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) <br />$ <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />$ <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 $56.00 <br />1986 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />$ <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK T.D. #(a) <br />L <br />— <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours min1mWTANK) <br /># TANK(s) X $234.00 = <br />3 <br />S <br />$ <br />$ <br />U <br />TEMPORARY CLOSURE (Plan Review & inspections) <br />TANK I.D. #(s) <br />R <br />$ <br />E <br />TEMPORARY CLOSURE FEE _ $78I..00/hour (3 hours minimun/TANK)# <br />TANK(s) X $234.00 = <br />S <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />A <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s)_X $234.00 = <br />N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum <br />$ <br />R <br />REPAIR FEE (Workplen Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />A, <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s)_X $234.00 = <br />5 � <br />3 <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) _ $234.00 minimum <br />$ <br />LEE <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum <br />$ <br />r M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br />I <br />S <br />C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78,00/hr $ <br />" e TOTAL DUE IS r <br />FOR OFFICE USE ONLY <br />iii .. � "^iiii::?i???�?i:iL•...:? • 3F! 31�7�.�uFEiF��FEIH�}iINUWi�884�[N&� 1 i}t: �:?!? L*•iASil9G4fU1?fifiSSi:nG????AJE'?AH !il?H?P?P.ffi! !?F1 <br />• SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY <br />I I ( DATE RECEIVED 09 <br />EH 23 032 (REVISED 11-1-92) ¢"' lC � Page 09 <br />3 <br />=AUH <br />:S <br />