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SAN JOAOUIN ' Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL I 'I DIVISION <br />UNL. ROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />� ::_s_--=::�:: s-:�==::: � :�:-:__ tea:::::_ <br />CHECK #/CASH I RECEIVED BY <br />DATE RECEII <br />T <br />E <br />FACILITY ADDRESSSITE <br />PHONE # with AREA CODE <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br />& <br />CITY <br />STATE <br />nr►_ <br />P CODE <br /># of TANKS ' <br />at SITE <br />A <br />A <br />I <br />`„� <br />LJ <br />R <br />P <br />P <br />APPLICANT/BILLING NAME <br />APPLICANAT NAME <br />L <br />PAN4- G iZAr-► ICJ l O <br />•CONTACT <br />S'' ^`� <br />I <br />C <br />A <br />MAILING ADDRESS <br />P. fox 30308 <br />APPLICANT PHONE # WITH AREA CODE <br />?,oq. 522. o4069 - <br />N <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APP <br />-- <br />(Closure(Installation etc.) <br />IUTAL <br />1986 1987 1988 1989 1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />A XXXX XXXX XXXX XXXX XXXX 5 XXXXXXXXXXXXX <br />C <br />T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX <br />I <br />V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br />E <br /># Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br />F (multiply # by fee for <br />A each year applicable) XXXX XXXX XXXX XXXX I XXXX $ <br />C <br />I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX I XXXX S <br />L <br />I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T 0 <br />Y #Tanks ( x $56.00 1988 through 1990 1991 through 1996 <br />(Enter amount and year) <br />C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />L <br />0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br />S <br />U TEMPORARY CLOSURE (Plan Review & Inspections) <br />R <br />E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />TANK I.D. #(s)_ <br /># TANK(s) <br />TANK I.D. 9(s)— <br />$234.00 minimum <br />X $234.00 = I S <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.O. #(s) <br />L-ov <br />A <br />N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br />ig <br />S <br />S 61± <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />� ::_s_--=::�:: s-:�==::: � :�:-:__ tea:::::_ <br />CHECK #/CASH I RECEIVED BY <br />DATE RECEII <br />E <br />5 <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />5 <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />$ <br />M TRANSFER FEE = 520.00 <br />I <br />S <br />C CONSULTATION FEE = 578.00/hr <br />FOR OFFICE USE ONLY <br />SWEEPS # <br />UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />SAMPLING INSPECTION FEE = 578.00/hr <br />S <br />I $ <br />TOTAL DUE I S <br />€€ ::: =fI €'s@ __ ::::...... <br />COMPUTER # <br />-:::: = €'s'ss s €s::::: ___s::_ -:::::::::::-... <br />I�LOC CODE I DIST CODE <br />v-_.— t _ -_� :::: <br />AMOUNT RECEIVED I <br />� ::_s_--=::�:: s-:�==::: � :�:-:__ tea:::::_ <br />CHECK #/CASH I RECEIVED BY <br />DATE RECEII <br />5 <br />