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SAN J0AQUIN C(X PUBLIC HEALTH SERVICES - ETIVIROMMENTAL HE DIVSIOR IMCY..ftdRC ARD STORAGE TANK PROGRAM - FEE WORKSHEET .i S FACILITY SITE NAME FACILITY CONTACT NAME ' KLNG �s�r>ND �J1� O'rJE,�L T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 E FACILITY ADDRESS SITE PHONE # with AREA CODE # TANK(s)_ X 5234.00 = ZN33y W. STIaTE t4u�Jre N so r)98-33(0'-1 & S A CITY STATE ZIP CODE # of TANKS STO C -K -M CQ q52. 0%. at SITE I F E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) P APPLICANT/BILLING NAME APPLICANT CONTACT NAME LNrACM1''- ter- VG1N6 XXXX C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE I 226 t�so NOGA� $10 158 33�y N T CIITY STATE ZIP CODETYPE of APPLICATION CL. us, R£ �"1-EASA NT ILS CPA 0, -Is Z3 (Closure, Installation, etc.) TOTAL C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) 1986 1987 1988 1989 1990 ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 A 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X 5234.00 = S S S A C TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = 5 T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX S I V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) E # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 F (multiply # by fee for S A each year applicable) C I TANK PENALTY FEES ASSESSED XXXXXX%X S L I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California X 8 S Code, Seetion 25287 T Y # Tanks x $56.00 1986 through 1990 1991 through 1996 (Enter amount and year) S C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) L A 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X 5234.00 = S S A U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = 5 P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) L A P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) H PLAN CHECK FEE = 578.00/hour (8 hours minimua/FACILITY) = 5624.00 minimum S R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) E P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S A I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 mini" S R PIPING REPAIR FEE = 578.00/hour (3 hours minimun/FACILITY) = 5234.00 minimum S M TRANSFER FEE = $20.00 I S C CONSULTATION FEE = 578.00/hr FOR OFFICE USE ONLY SWEEPS # 1 COMPUTER 0 1 LOC UNAUTHORIZED RELEASE EVALUATION = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr EH 23 032 (REVISED 11-1-92) Page 11 S S TOTAL DUE S BY I DATE RECEIVED