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0 <br />1 <br />SAN JOAQUIN Ca PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEAODIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAME / <br />FACILITY CONTACT NAME <br />E <br />T <br />E <br />FACILITY ADDRESS 1 <br />SITE PHONE # with AREA CODE <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />A <br />CITY <br />%/ <br />STATE <br />� <br />ZIP CODE <br /># of TANKS <br />at SITE <br />_ $234.00 minimum <br />/ <br />P <br />PAPPLICANT <br />BILLING NAME <br />APPLICANT CONTACT NAME <br />lei <br />CS <br />�✓��`S ©O <br />C <br />MAILING ADDRESS / <br />APPLICANT PHONE # WITH AREA CODE <br />N <br />T <br />CITY <br />STATE ZIP CODE TYPE of APPLICATION4112- <br />CS <br />Cid <'J? ��� (Closure, Installation, etc. )� <br />TOTAL <br />1986 1987 1988 1989 1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />A $ <br />C <br />T FACILITY PENALTY FEES ASSESSED (if Applicable) X)O(I( xxxx $ <br />I <br />V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br />E <br /># Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1 1994 1995 1996 <br />F (multiply # by fee for <br />A each year applicable) $ <br />C <br />I TANK PENALTY FEES ASSESSED xxxx xxxx $ <br />L <br />I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T <br />Y # Tanks x $56.00 1986 through 1990 1991 through 1996 <br />(Enter amount and year) <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) <br />TANK I.O. #(s) <br />E <br />L <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = $ <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum <br />S <br />R <br />R <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimWFACILITY) <br />_ $234.00 minimum <br />$ <br />P INSTALLATION PLAN CHECK (Plan. Review & Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minima /TANK) <br /># TANK(s) X $234.00 = <br />$ <br />A <br />(,'TANK <br />RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum <br />$ <br />FOR OFFICE USE ONLY <br />...........................................................................................,...................................................,...................,........................,................................................................, <br />...1........................ ......................... <br />EH 23 032 (REVISED 3-1-93) <br />Paae 11 <br />...... ....................... p..... .... <br />