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SAN JOACUIN STT PUBLIC HEALTH SERVICES <br /> ND - ENVIRONMENTAL•TH DIVISION <br /> GROUSTORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME K <br /> FACILITY CONTACT NAME <br /> 1 <br /> T <br /> E FACILITY ADORESS SITE PHONE # u h AREA CODE <br /> a <br /> EID Ad. <br /> CITY � / STATE ZIP CODE # of TANKS <br /> A �/7 C) C C at SITE / <br /> P <br /> P APPLICANT/BILLING NAME /7 APPLICANT CONTACT NAME <br /> I APPLICANT PHONE # WITH AREA CODE '`f 7 j <br /> C MAILING ADDRESS <br /> N 0 <br /> 55555'77777�A,[rr�E ZIP CODE TYP APPLICATION <br /> T CITY G � y�/ Iosure Installation, etc.) <br /> TOTAL <br /> 1986 1 1987 11988 11989 1 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX I %XXX I XXXX I %XXX XXXX S XX%XX%XXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX I XXXX I %XXX I XXXX I Xxxx S %XXXXXXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks 1986 1987 1988 1989 1990 1991 1 <br /> 1993 1994 1995 1996 <br /> F (multiply # fee for 70 �/ / <br /> A each year applicable) %xxx XXXX XXXX %XXX X%XX /770 /70 70 � /d /101 1 1Q 70 S <br /> ` /\ ''`` EV <br /> 1 TANK PENALTY FEES ASSESSED XX%% XXXX XXXX I XXX% XXX% "1(� � D � 7V U <br /> L <br /> 1 STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H a S Code, Section 25287 <br /> T <br /> Y # Tanks/ x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount aril year) OV-- 1 00 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.O. #(s) <br /> -- <br /> L = = I # TANK(s)_ X 5234.00 = S <br /> 0 CLOSURE FE_ 578.00/hour (3 hours minimum/TANK) <br /> S <br /> U TEMPORARY CLOSURE (Plan Review a Inspections) TANK 1.0. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimuv/FACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review a Construction Inspections) TANK t.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minim n/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review a Construction Inspections) I TANK I.O. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5734.00 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hrSAMPLING INSPECTION FEE = 578.00/hr I 5 'o) S a <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY --- <br /> SWEEPS # COMPUTER # I LOC CODE I OIST CCOE I AMOUNT RECEIVE? CHECK #/GSH I RECEIVED BY DATE RECEIVED <br /> ................. ..........._......._....... _. T.__- <br /> - .._.._......__..................._....._......--- --.....__.._...-._..._......_...- - -- --= - - <br />