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SAM JOAOUIM MTV PUBLIC HEALTH SERVICES - ENVIROMMEXTAL LTH DIVSION <br /> L' •.GROUND STORAGE TANK PROGRAM FEE NORKSHEE <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> 1 Tracy Golf and Country Club <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA LOGE <br /> 35200 Chrisa!an Road <br /> i <br /> CITY IP CODE I # of TANKS <br /> A Tracy G 95376 at SITE 1 <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITY <br /> (Closure, InstaLlation, eta.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 $100 5100 $100 $100 5100 S 500.00 <br /> A <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) 5100 $100 $100 1 5100 $100 S 500.00 <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1 1986 1 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) 550S50 S50 $50 850 $ 250.00 <br /> C <br /> I TANK PENALTY FEES ASSESSED $50 $50 S50 S50 $50 S 250.00 <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H i S Code, Section 25287 <br /> T <br /> Y # Tanks 1 11S56'00 <br /> 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> $56 S 16.00 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours miniffKmVTANK) # TANK(s)_1_ X $234.00 = S 234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review i Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review i Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) _ %24.00 minimum 5 <br /> R REPAIR FEE (Workplan Review i Construction Inspections) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours miniaua/TANK) # TANK(s) _ X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr $ <br /> TOTAL DUE S 1790.00 <br /> FOR OFFICE USE ONLY <br /> __ _ ., <br /> _ <br /> SWEEPS # COMPUU TER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/GSH RECEIVED BY DATE RECEIVED <br /> a <br /> S = <br /> ,.s.—.............. :_..__........._...__.._..�:::..__.__............. ——__ — - <br /> EH 23 032 (REVISED 4-6-95) <br />