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R - SAN JOAQUIN co mBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVSION UNDER SrORAGE TANK PROGRAM - FEE WORKSHEET –S —FACILITY SITE NAME FACILITY CONTACT NAME I 1987 1988 1989 1990 CLOSURE FEE = $78.00/hour (3 hours mini TANK) ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 T E FACILITY ADDRESS SITE PHONE # with AREA CODE A S U & XX)O( R E $ $234.00 minimum $ CITY STATE ZIP CODE of TANKS Eat A FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX SITE S I V TANK FEE = $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) E # Tanks = P P APPLICANT/BILLING NAME APPLICANT CONTACT NAME L 1990 1991 1992 I C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE A (multiply # by fee for each year applicable) XXXX N T CITY STATE ZIP CODE TYPE of APPLICATION (Closure, Installation, etc.) TOTAL CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) 1986 1987 1988 1989 1990 CLOSURE FEE = $78.00/hour (3 hours mini TANK) ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 5 A S U XXXX XX)O( R E $ $234.00 minimum $ PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ C T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX S I V TANK FEE = $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) E # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 F A (multiply # by fee for each year applicable) XXXX XXXX $ C I TANK PENALTY FEES ASSESSED XXXX XXXX S L I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 T Y # Tanks x $56.00 1988 through 1990 1991 through 1996 (Enter amount and year) S CPERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) L 0 CLOSURE FEE = $78.00/hour (3 hours mini TANK) # TANK(s) X $234.00 = 5 S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ P INSTALLATION PLAN CHECK (Plan Review & Constriction Inspections) TANK I.D. #(s) L TANK LINING REPAIR FEE = 578.00/hour (3 hours minima /TANK) A N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum S R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) E P TANK LINING REPAIR FEE = 578.00/hour (3 hours minima /TANK) # TANK(s) X $234.00 = S A I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hers min./FACILITY) _ $234.00 minimum S R PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ M TRANSFER FEE = $20.00 I S C CONSULTATION FEE = $78.00/hr FOR OFFICE USE ONLY UNAUTHORIZED RELEASE EVALUATION = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ 5 TOTAL DUE S SWEEPS # I COMPUTER # I LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK #/CASH I RECEIVED BY I DATE RECEIVED 5 EH 23 032 (REVISED 10-28-93)