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SAN JOAQUIN a ( PUBLIC HEALTH SERVICES - ENVIRONMENTAL Hi H DIVSION <br /> UMUeRGROLMO STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FAC141TY SITE NAME FAITY CONTACT NAME <br /> T <br /> E FACILITY JIDDRESS SITE PHONE # with AREA <br /> 5 S '/T/ (o -S <br /> y STATE P CODE # of TANKS <br /> A f T� at SITE 2 <br /> P Y <br /> P APPLICANT/BILLING E APPLICANT CONTACT NAME <br /> ` t � eO" r6a,( SI <br /> CILING ADDRAS _ APPLICANT PHONE # WITH AREA CODE <br /> M <br /> T Y STATE ZIP CODE TYPE of APPLICATION <br /> f � (C osure Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 1986 1987 1988 1989 1990 <br /> A %XX% %XXX S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXX% XX%X f <br /> 1 <br /> V TANK FEE 850.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks 1986 1987 1988 1989 7990 1991 1992 1993 1 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XX%X E <br /> C <br /> I TANK PENALTY FEES ASSESSED XXX% X%%% E <br /> L <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y it Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 878.00/hour (3 hours minimum/TANK) # TANK(s) 'g% 5234.00 = f <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> M! PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minis. s <br /> R REPAIR FEE (workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = f <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 mini mm E <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 mini mm E <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr E <br /> 1 <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr E <br /> TOTAL DUE f <br /> FOR OFFICE USE ONLY <br /> -_:__:::-::-:--.-:-:-:--.-.:—:-..........___.__......... _:::::::::::___::.-..—_:__:::,.-:::::::::::::-�:::::::::::::::::::--::::--_. _..___.-:. <br /> ._.__......._...._.........._......................................._............_.__.___.._..._...........................___.___.......__....................................................._......._..._...._._............__._.._..........._:::::�::::::::_:. :...�:_ <br /> �__::::::�_.:::_.._....... ........._.......,,_�::...:.....::................::�__rr_!!c;:!�:a_=.:::e:::::::::::::::.................__...._..._ .��-.=,!eca:s;�::::-s!!!!!!__!!!s::!t_�._!_!!!!!pa+'�' <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> E - <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />