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E3 <br />SAN JOAQUIN C / PUBLIC HEALTH SERVICES - ENVIRONMENTAL H 1 DIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET'-' <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />I <br />T <br />New. . a_r ra, Q/�(� <br />tyh if e- l <br />E <br />fACIIITY ADDRESS <br />SITE PHONE # with AREA CODE <br />& <br />8au c -L s + <br />a "I s i <br />A <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS ^ <br />at SITE <br />P <br />(After January <br />C- <br />O 7 <br />.2- k - <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT COTNTA�CT, <br />1988 <br />1989 <br />/INAME <br />41 �(. lA <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />N <br />(L ...-. �r <br />S/O Af.26 Z <br />T <br />CITYn <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />41 <br />Y �f�A r <br />CR <br />ytSg $ <br />(Closure, Installation, etc.)C�obu�2 <br />A <br />C <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />1986 <br />1 987 1988 <br />1989 <br />1990 <br />5 <br />T <br />I <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />X)00( <br />5 <br />V <br />E <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK <br />(After January <br />1, 1991) <br />F <br />A <br />C <br /># Tanks = <br />(multiply # by fee for <br />each year applicable) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 1991 1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />41 <br />S <br />I <br />L <br />TANK PENALTY FEES ASSESSED <br />)OXX <br />XXXX <br />S <br />I <br />T <br />STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />Y <br /># Tanks z $56.00 <br />(Enter amount and year) <br />1986 through 1990 <br />1991 through 1996 <br />S <br />C <br />L <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />0 <br />S <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) l X $234.00 = <br />— <br />5 <br />3 L4 <br />U <br />R <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimLWFACILITY) <br />= S234.00 minimum <br />f <br />P <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/ FACILITY) $624.00 minimum <br />5 <br />R <br />E <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />P <br />A— <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) <br /># TANK(s) X 5234.00 = <br />5 <br />I <br />R <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum <br />$ <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimuNFACILITY) = 5234.00 minimum <br />S <br />M TRANSFER FEE = S20.00 <br />5 <br />C I CONSULTATION FEE = S78.00/hr <br />UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />SAMPLING INSPECTION FEE - S78.00/hr <br />5 <br />S <br />TOTAL DUE 15 <br />EM 23 032 (REVISED 3-1-93) Pace 11 <br />