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SAN JOAQUIN * PUBLIC HEALTH SERVICES _ ENVIRONMENTAL NOH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> gA <br /> ITY SITE NAME <br /> Y- C( J N �`�I�� FACfLITY CONTACT NAME <br /> �� -'u <br /> ITY ADDRESS "-7 �" • " !'�l�Jt{.�� <br /> �1' <br /> - � 1 SITE PHONE # with AREA CCOE <br /> �.� TATE ZIP_CDDE # of TANKS <br /> at SITE <br /> ANT/BILLING N\A�ME�(� �`YAPPJ.ICANT CONTACT NAME <br /> LTG ADDRESS { �-t-1 J /l��% V V > T ✓T L(�0 APPLiC'N3 PHONE #. HAREA COpEI% <br /> STATE ZIP CODE TYPE Of APPLICATION �(l ��!' rL <br /> S'i©con <br /> (Closure, Installation, etc.) <br /> �7�7 ") <br /> TOTAL <br /> A ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 1986 1987 1988 1989 1990 <br /> D xxxx xxxx $ <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I xxxx xxxx $ <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,19917 <br /> E 1170/TANK (After January 1, 1991) <br /> # Tanks = 1986 1987 1988 11989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply ##oy fee for <br /> A each year applicable) XXXX XXXX <br /> C <br /> S <br /> I TANK PENALTY FEES ASSESSED XXXX %xXX <br /> L $ <br /> I STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) <br /> T See California H 3 5 Code, Section 25287 <br /> Y # Tanks x $56.00 1988 through 1990 <br /> (Enter amount and year) 1991 through 1996 <br /> f <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.O. #(s) <br /> L <br /> 0 CLOSURE FEE = $78,00/hour (3 hours minimNm/TANK) <br /> S # TANK(s) <br /> _ % $234.00 = f <br /> U TEMPORARY CLOSURE (Plan Review d Inspections) <br /> R TANK I.D. #(S) <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimm/FACILITY) $234.00 minimm <br /> S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours Minimum/FACILITY) = $624.00 minimm $ <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) <br /> E TANK [.D. #(5) <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimun/TANK) # TANK(s) __ X S234,00 = <br /> A $ <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = 5234.00 minimum R $ <br /> PIPING REPAIR FEE = $78.00/hour (3 hours minimAR/FAC(LITY) = SZ34,00 minimus <br /> S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = $78,00/hr <br /> I $ <br /> S <br /> C CONSULTATION FEE _ $78.00/hr <br /> SAMPLING INSPECTION FEE = 878.00/hr <br /> f <br /> FOR OFFICE USE ONLYTOTAL DUE $ <br /> ::::—.Ti _�._: <br /> SWEEPS # I COMPUTER # LOC CODE DIST CODE AMOUNT .RECEIVED—CHECK v#/CAS-H— <br /> RECEIVED BY �i 'DATE RECEIVED - <br /> EH 23 032 (REVISED 10-28.93) Page11 ��� <br />