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SAN JOAQUIN CLO PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEJ&IVSION <br />UNDcwGROUNO STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACTCcLE <br />�C� <br />T <br />�AlJS�N S <br />C[o�- <br />1990 <br />E <br />FACILITY ADDRESS <br />2 3M <br />SITE PHONE # with AREA CLUE <br />'Zow ci -3-115 <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />- s - <br />8 <br />S <br />I <br />V <br />A <br />CITY �\ <br />STATE <br />ZIV CODE <br />of at SITE <br />E <br />F <br />A <br /># Tanks = <br />(multiply # by fee for <br />each year applicable) <br />1986 1987 <br />1988 <br />PNKS <br />1990 1991 1992 <br />1993 <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />Ir _2 X2,.1 � <br />Co 8 a <br />C <br />MAILING ADDRE S <br />�L55(� N�7� <br />APPLICANT PHONE # WITH AREA CODE <br />`I�3- <br />N <br />Fs—. <br />4 3&� <br />:±i::: <br />_—::EE <br />S <br />L <br />I <br />STATE SURCHARGE = 856.00 each TANK (Due every 5 years) See CaLifornia H 8 S Code, Section 25287 <br />T <br />CITY <br />STATE <br />ZIP CODE <br />T APPLICATION <br />$ <br />1 51Ot-��7 <br />%1j.2 <br />Closure Installation, etc.) <br />TOTAL <br />A <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />S <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX <br />S <br />I <br />V <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK <br />(After <br />January <br />1, 1991) <br />E <br />F <br />A <br /># Tanks = <br />(multiply # by fee for <br />each year applicable) <br />1986 1987 <br />1988 <br />1989 <br />1990 1991 1992 <br />1993 <br />1994 1995 1996 <br />5 <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX XXXX <br />� <br />:±i::: <br />_—::EE <br />S <br />L <br />I <br />STATE SURCHARGE = 856.00 each TANK (Due every 5 years) See CaLifornia H 8 S Code, Section 25287 <br />T <br />Y <br /># Tanks x 556.00 <br />(Enter amount and year) <br />1986 through 1990 1991 through 1996 <br />$ <br />CPERMANENT <br />CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = 878.00/hour (3 hours minimm/TANK) # TANK(s) X $234.00 = <br />f <br />S <br />U <br />TEMPORARY CLOSURE (PLan Review 8 Inspections) TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) = S234.00 minimum <br />S <br />P <br />INSTALLATION PLAN CHECK (PLan Review 8 Construction Inspections) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = 878.00/hour (8 hours minimum/FACILITY) = S624.DO minimum <br />$ <br />R <br />REPAIR FEE (Workplan Review 8 Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) _ X 5234.00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 mini mm <br />$ <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = $234.00 mini mm <br />5 <br />M TRANSFER FEE = $20.00 <br />I <br />S <br />C CONSULTATION FEE = 578.00/hr <br />FOR OFFICE USE ONLY <br />UNAUTHORIZED RELEASE EVALUATION = 478.00/hr <br />SAMPLING INSPECTION FEE = 578.00/hr <br />F3 <br />13 <br />TOTAL DUE I S <br />EH 23 032 (REVISED 3-1-931 Pace 11 <br />