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SAN JOAQUIN CDm T PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE—.H D[VSION <br /> UNDERGRa= STODGE TANK PROGRAM - FEE WORKSHEET <br /> SI FACILITY SITE NAME FACILITY CONTACT NAME <br /> I� <br /> T <br /> E FACILITY ADDRESS SITE PHONE % with AREA CODE <br /> i <br /> CITY STATE ZIP C % of TANKS <br /> A at SITE <br /> P <br /> P APPLICANT/8ILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C NAILING ADDRESS APPLICANT PHONE X WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 11988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX ( X)Ca I a j /00 f 2Gr� <br /> C <br /> T fACIIITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX I /(h'7 1,160 <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 11990 1991 11992 1993 11994 1995 1996 <br /> F (multiply % by fee for <br /> A each year applicab(e) XXXX XX:(X <br /> II TANK PENALTY FEES ASSESSED I XXXX XXXX I �QO S <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H i S Code, Section 25287 <br /> T <br /> T % Tanks X 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S A/ <br /> Cl PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. %(s) —/ 0 <br /> L <br /> OI CLOSURE FEE - 578.00/hour (3 hours minimum/TANK) % TANK(s) X S234.00 = $ p ) Q <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 3 Inspections) TANK I.D. %(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br /> PI INSTALLATION PLAN CHECK (Plan Review i Construction Inspections)i TANK 1_9. %(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimWFACILITY) = S624.00 minimum S <br /> R REPAIR FEE (Workplan Review i Construction Inspections) TANK I-0. %(s) <br /> E <br /> PI TANK LINING REPAIR FEE = S78.00/hour (3 hours minimWTANK) % TANK(s) _ X S234.00 = S <br /> A <br /> 11 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours •min./FACILITY) = S234.00 minimun S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours mini=WFACILITY) = S234.00 minimum S <br /> NI 'RANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 378.00/hr f <br /> I <br /> S <br /> Cl CONSULTATION FEE 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S Z <br /> FOR OFFICE USE ONLY <br /> SWEEPS % COMPUTER LOC CODE DIST CODE AMOUNT RECEIVED CHECK 4/CASH RECEIVED 3Y DATE RECEIVED = <br /> S <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />