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�1 v SAN JOAQUIN COLAI�LIC HEALTH SERVICES - ENVIRONMENTAL W-ALOIVS10M � <br /> / � a UNDERGAOIAD STORAGE PROGRAM - 'FEE WORKSHEETWORKSHEET'x, <br /> S FACILITY SITE NAME 1 FACILITY CONTACT NAME �y <br /> T SITE PHONE # with AREA CODE <br /> E FACIL T ADD ESS <br /> f <br /> L <br /> CIT M <br /> # of TANKS <br /> at SITE 57 <br /> A <br /> Azu� <br /> P <br /> P APPLI NT/BILLING NAM NT CONTACT NAME <br /> L � <br /> I <br /> C MAI/LING ADDRESS NT PHONE #�[WITH <br /> /AREA CODE <br /> N / 6)3 � � T' '' <br /> T CITY TYPE of APPLICATION <br /> (Closure, installation, eterx TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 S <br /> A XXXX xxxx <br /> C S <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) XXXX XXXX <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 /> = <br /> F (multiply # by fee for <br /> A each year applicable) xXXX XxXX <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX <br /> g 5 � C�b <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.001988 through 1990 1991 through 1996 <br /> (Enter amount and year) S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L # TANK(s) X S234.00 = $ <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <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) % $234.40 = S <br /> P INSTALLATION PLAN CHECK (PLan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A S <br /> $624.04 minimum <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/flour (3 hours minimm/TANK) # TANK(s) X $234,00 = _ <br /> A 5 <br /> $234.00 minimum <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = <br /> RS <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION 578.00/hr 5 <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE $ 00 <br /> FOR OFFICE USE ONLY -----._._............._ a :: ;:::::;:::e:::::::._.:::::a:at:¢-s!::;: :-::......... <br /> _................._................,.................................. ------...............�._... ............................... .................... .............,..e <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED = <br /> _. - ............................. ..... _....................:......................... ....... <br /> _..,...... ............................................._......... _ <br /> ................................................. r,.....;:. ........ __........:::............_««,:• <br /> ... ........._........................ _..._.........«.........,. _... ....... <br /> EH 23 032 (REVISED 6-21-93) Page 11 <br />