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. SAN JOAOUIN CQ�Y PUBLIC HEALTH SERVICES - ENVIROINENTAL H& DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FAC]LT SITE NAME FACILITY CONTACT NAME / 373 _l/6,� <br /> T <br /> E FACILITY ADDRESS LSITE PHONE # with AREA CODE <br /> as- <br /> CITY STATE ZIP CODE # of TANKS <br /> Ash at SITE <br /> P, <br /> P APPLICANT/81LL1 G NAME _ APPLICANT CONTACT NAME <br /> 1/0 <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A ? �: 1 '-z <br /> N <br /> T CITY STATE ZIP CODE TY PPLICATION <br /> Innsstaallatllat <br /> C � Deur , ion, exc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A xxxx xxxx $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx S <br /> 1 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 9 Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) xxxx xxxx f <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx S <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 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> 1, 5 <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) ~'.'Y/1 — j 9f A `a` <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 = S <br /> t <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/TANK) # TANK(s) X $234.00 = S <br /> P INSTALLATION PLAN CHECK (Pian Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minima/FACILITY) = $624.00 minimum $ <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 S234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 378.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> - ---................................................................._.......•.....................__..._......::::-::::::::::-:::_:-:_-::::::_...... ::::::::::::r..-:-:.—.-::.--........ ...::-:::-::::::::::::::::::-:::::.-_::.-:::---.— <br /> .................. <br /> ........................,............ <br /> ........_................. <br /> ................................. w....,._................. <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> $ - <br /> _....__......................................_....................,........................._................................................. <br /> EH 23 032 (REVISED 6-21-93) Page 11 <br />