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SAN JOAQUIN �IC HEALTH SERVICES - ENVIRONMENTAL HE IVSION <br /> STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I 7'-)c Vz 'S&\C.l');r-, <br /> T <br /> E FACILITY ADDRESSTE PHONE # with AREA CODE <br /> L4osl °,. oc� '209 a`i3 - Q '(� <br /> CITY �cWE ZIP CODE # of TANKS <br /> A t'CSG�t'°,^ Lrt at SITE <br /> P <br /> P APPL] ANT/BILLING MAJE APPLICANT CONTACT NAME <br /> L 7 <br /> C2[ 5 SoGI CL4C-'�' <br /> C MAILING ADDRESS PLICANT PHONE # WITH AREA CODE <br /> A 11 3 a-aril �� Cj�UG� <br /> Tj CIT1(� TE JI QOQL 1 TYPE of APPLICATION <br /> rCtosure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX xxxx $ <br /> I <br /> V TANK FEE _ 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1 1988 1989 1990 1991 1992 F 1993 1994 1995 1996Iji(p��j?j <br /> F (mu lti (y71-6—fee for <br /> A each year apQlicabie) XXXX XXXX XXXX <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX 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 ill 0� 3 <br /> (Enter amount and year) iQQ S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Plate) TANK I.D. #(s) 18to'a - I�JIJAN Uk <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimun/TANK) # TANK(s) X $234.00 = 4 '� ,C)C) <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK 1.0-44s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78,00/hour (3 hours minimum/FACILITY) $234.00 minimum 5 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) (}jIDlo <br /> L <br /> A d <br /> N PLAN CHECK FEE = 478.00/hour (8 hours minimum/FACILITY) = 4624.00 minimum <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I_D. #(s) <br /> P'� TANK LINING REPAIR FEE = 478.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I 7ANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr 4 <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr 4 <br /> TOTAL DUE S <br /> OFF U ON - <br /> QR....._......LSrF........ .......i X........................... .. »: :: -••--..........................................................................................:...........:......:. <br /> ::::::::::::...........:: ::::::::::::: .1-.... ::::::::::::::::::::::[::.::.:::::::::::::s <br /> ir, <br /> SWEEPS # COMPUIC-k # _ALO : CODE 61ST-CODC AMOl1N7 s7CC 1'JED CHI=CK k%CASii R!C 1Vl D AY __._-DAYI REC( IVED rF <br /> $ <br /> ails <br /> EH 23 032 (REVISED 4-29-94) Page 11 <br />