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SAN JOADUIN COIAITT PUBLIC HEALTH SERVICES - ENVIROIDIENTAL HEALTH DIVSiON <br /> LNDERGROIND STORAGE TANK PROGRAM - FEE VORKSHEET <br /> S FACVTY SITE NAME FACILITY CONTACT NAME <br /> I II.,.\\JJ - PRo e T <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> CITY / STATE ZIP CODE # of TANKS <br /> A SG/G,C D�� at SITE / <br /> P <br /> P APPA NT/BILLING NAME APPLICANT CONTACT MANE <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> STA E IP CODE TYPE APPLICATION <br /> 7 LITY G� / _ _ ,l osure Installation, 2te.) 17, <br /> r` <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 <br /> A )0= xx)D( xxxx XXXK /do $/Q0 <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If APplicahle) )000( XXXX %)00( XXXX Qo 5 <br /> I <br /> v TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E # Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # fee for qn r, <br /> A each year appLicable) X%XX XXXX XXXX XX%X — L'1 7c 70 1L '17 61 lV 5 900 <br /> C <br /> I TANK PENALTY FEES ASSESSED %%XX XXXX %%XX XXXX i.) D ' 7L1 G $ <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> T # Tanks—L x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) TANK I.O. #(s) <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)�— X 5234.00 = S'�e <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 minimum/FACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hcur (8 hours minimum/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 minimum/TANK) # TANK(s) X 5234.00 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = E78.00/hour (3 hours mini mum/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> 5 <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE Ll_ <br /> FOR OFFICE USE ONLY --- <br /> _[[_=_—,.'�.-':r__........_.......__._..,_..—�_..____._.._ .........,_' ... _ <br /> SWEEPS # I COMPUTER # LOC CODE,.I =DIST CODE AMWNT RECEIVED I CHECX #/CASH I RECEIVED BY DATE RECEIVED <br /> L _ <br /> TEH 23 032 <br /> law vn/ <br />