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SAN JOAOUIM COV' - PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE I DIVSIOI IRM "M STORAGE TANK PROGRAM - FEE WORKSHEET._. S FACILITY SITE NAME FACILITY CONTACT NAME IV� �,v K 1989 1990 LOC CODE DIST CODE AMOUNT RECEIVED CHECK N/CASH T E FACILITY ADDRESS a✓ e- SITE PHONE I with AREA CODE N TANK(s) X !234.00 = u T' i� — f A CITYv / STATE ZIP CODE 206 4v R of TANKS at SITE ::................_....__._.....!.-..—r:...-�. ................_..-._._.... 1 TEMPORARY CLOSURE (Plan Review d Inspections) S R P P APPLICANT/BILLING NAME APPLICANT CONTACT NAME L ma 1 C MAILING ADDRESS APPLICANT PHONE N WITH AREA CODE XKXX XXXX M I CITY STATE ZIP CODE TY PPLICATION fe �^ 2630 (Closure Installation, etc.) TOTAL C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) 1986 1987 1988 1989 1990 LOC CODE DIST CODE AMOUNT RECEIVED CHECK N/CASH ANNUAL FACILITY FEE (Prior to January 1, 1991) _ S100.00 0 CLOSURE FEE = 978.00/hour (3 hours minimum/TANK) N TANK(s) X !234.00 = f S - A f XXXX XXXX ::................_....__._.....!.-..—r:...-�. ................_..-._._.... U TEMPORARY CLOSURE (Plan Review d Inspections) S R ......____......._..._._...._..._..__...,_ _:-!_x:_=r:;:x�r::E:'�_�::!w=_!!s_!!r!.u!=..-e_=_!!e!!:_�:!a!:-!t:!!!_"-:a!:+.!:!!!::!rim!!t_!5;==--a;t"�:!!!!!•_5!!=!!`!!!!::_=!�!:::,s!!wc�n!!Mx:.sxna!�,:�:!:.:rs:m!�4�:!!!!rn„!!s!s R gmm,.a±=*:=.�!m!v.��srzmen_�:!# E C T FACILITY PENALTY FEES ASSESSED (if Applicable) XKXX XXXX f I V TANK FEE _ $50.00/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 R by fee for XXXX KXXX — $ A each year applicable) C — —+— I TANK PENALTY FEES ASSESSED XXXX XXXX 1 L 1 STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California N d S Code, Section 25287 T Y 1 Tanks x $56.00 1988 through 1990 1991 through 1996 (Enter amount and year) C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. M(a) L ..r::::Fse::!=.::ie!i==i!__rii�:=.!ii=�;;i�;t:_!-as_ �_�_�_-t;=;�;,eFi-3 SWEEPS M L LOC CODE DIST CODE AMOUNT RECEIVED CHECK N/CASH A 0 CLOSURE FEE = 978.00/hour (3 hours minimum/TANK) N TANK(s) X !234.00 = f S - f - ::................_....__._.....!.-..—r:...-�. ................_..-._._.... U TEMPORARY CLOSURE (Plan Review d Inspections) TANK I.D. N(a) R ......____......._..._._...._..._..__...,_ _:-!_x:_=r:;:x�r::E:'�_�::!w=_!!s_!!r!.u!=..-e_=_!!e!!:_�:!a!:-!t:!!!_"-:a!:+.!:!!!::!rim!!t_!5;==--a;t"�:!!!!!•_5!!=!!`!!!!::_=!�!:::,s!!wc�n!!Mx:.sxna!�,:�:!:.:rs:m!�4�:!!!!rn„!!s!s R gmm,.a±=*:=.�!m!v.��srzmen_�:!# E TEMPORARY CLOSURE FEE = 978.00/hour (3 hours minimum/TANK) 0 TANK(s) X $234.00 = S P INSTALLATION PLAN CHECK (Plan Review d Construction Inspections) TANK I.D. N(a) L ..r::::Fse::!=.::ie!i==i!__rii�:=.!ii=�;;i�;t:_!-as_ �_�_�_-t;=;�;,eFi-3 SWEEPS M COMPUTER 11 LOC CODE DIST CODE AMOUNT RECEIVED CHECK N/CASH A P TANK LINING REPAIR FEE = $78.00/hour (3 hours minirmm/TANK) M PLAN CHECK FEE = !78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S R REPAIR FEE (Workplan Review d Construction Inspections) TANK I.D. R(s) E ..r::::Fse::!=.::ie!i==i!__rii�:=.!ii=�;;i�;t:_!-as_ �_�_�_-t;=;�;,eFi-3 SWEEPS M COMPUTER 11 LOC CODE DIST CODE AMOUNT RECEIVED CHECK N/CASH RECEIVED BY DATE RECEIVED P TANK LINING REPAIR FEE = $78.00/hour (3 hours minirmm/TANK) M TANK(s) X $234.00 = S A - f - ::................_....__._.....!.-..—r:...-�. ................_..-._._.... 1 TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum S R ......____......._..._._...._..._..__...,_ _:-!_x:_=r:;:x�r::E:'�_�::!w=_!!s_!!r!.u!=..-e_=_!!e!!:_�:!a!:-!t:!!!_"-:a!:+.!:!!!::!rim!!t_!5;==--a;t"�:!!!!!•_5!!=!!`!!!!::_=!�!:::,s!!wc�n!!Mx:.sxna!�,:�:!:.:rs:m!�4�:!!!!rn„!!s!s gmm,.a±=*:=.�!m!v.��srzmen_�:!# PIPING REPAIR FEE = 178.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum f MI TRANSFER FEE _ !20.00 Ir CONSULTATION FEE _ $78.00/hr FOR OFFICE USE ONLY UNAUTHORIZED RELEASE EVALUATION = !78.00/hr SAMPLING INSPECTION FEE = $78.00/hr S 11 TOTAL DUE I f ._ .., __.............__._...,.,,_.,._.._......,::a:=-::::::::__........_..: :�;::=_a!:e!!!!!___,:. ..... ___;.—__..__....._. ..r::::Fse::!=.::ie!i==i!__rii�:=.!ii=�;;i�;t:_!-as_ �_�_�_-t;=;�;,eFi-3 SWEEPS M COMPUTER 11 LOC CODE DIST CODE AMOUNT RECEIVED CHECK N/CASH RECEIVED BY DATE RECEIVED - f - ::................_....__._.....!.-..—r:...-�. ................_..-._._.... . ....... _ ___ :_.___.._..__.__....._..............� _......_:.. ::m:9:r..:.,::m:::,,::,.:::.—.- _ ,..,::rrm ......____......._..._._...._..._..__...,_ _:-!_x:_=r:;:x�r::E:'�_�::!w=_!!s_!!r!.u!=..-e_=_!!e!!:_�:!a!:-!t:!!!_"-:a!:+.!:!!!::!rim!!t_!5;==--a;t"�:!!!!!•_5!!=!!`!!!!::_=!�!:::,s!!wc�n!!Mx:.sxna!�,:�:!:.:rs:m!�4�:!!!!rn„!!s!s gmm,.a±=*:=.�!m!v.��srzmen_�:!# EH 23 032 (REVISED 6-21-93) Page 11