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1. SAN JOAQUIN C T PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE 1 DIVSION <br /> UILR6ROUNI) STORAGE TANK PROGRAM - FEE WORXSHEET� <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I � <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & Z L G7 510 - <br /> CITY STATE ZIP CODE # of TANKS <br /> A (+ (�.. at SITE 2 <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> ( (.�l(C 4 <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> " <br /> N l w1L1> -L_c_ 't -'165-1foko <br /> T CITY STATEI ZIP CODE TYPE APPLICATION <br /> Closure, Installation, etc.) <br /> TOTAL <br /> 1 ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 1986 1987 1988 1989 1990 <br /> A %XXX xxxx XXX% xxxx S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) X%xx xxxx <br /> xxxx I %XX% S <br /> I <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1966 11987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # byby fee for <br /> A each year applicable) )0= xxxx xxxx xxxx S <br /> C <br /> I TANK PENALTY FEES ASSESSED I )OODf I xxxx xxxx xxxx I I S <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(5) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) Z X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) $234.00 minimum 5 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours miniaWTANK) # TANK(s) x 5234.00 = 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 minimua/FACILITY) = 5234.00 minimum $ <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION - 278.00/hr s <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S 76 <br /> FOR OFFICE USE ONLY <br /> 3 SWEEPS # COMPUTER # LOC CODE I DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED a <br /> S <br /> EN Z3 032 (REVISED 4-6.95) <br />