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' SAN JOAQUIN COINCL1C HEALTH SERVICES - ENVIRONMENTAL HEALL0DIVSSON <br /> UNDERGRIX1la1 STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY CONTACT 17, <br /> S FACILITY SITE NAME <br /> II e(! S SITE PHONE # with AREA CODE <br /> TSfE FAC.j.-1L ITtADORE55 <br /> & v\ STgTE ZIP CODE # of TANKS <br /> CITY �n (� 1, at SITE <br /> A <br /> P APPLICANT CONTACT NAME <br /> L APPLICANT/BILLING NAME / �� n: <br /> - •�p`y`� APPLICANT PHONE # WITH AREA CODE <br /> I <br /> C MAILING ADDRESS r <br /> A 4 L-� �Q'✓� � .d <br /> M STATE 21P CODE TYPE of APPLICATION •*, k <br /> T CITY (Closure, Installation, <br /> TOTAL <br /> 1966 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 xxxx X)= ��� S rl <br /> A S <br /> CI xxxx I X)00( !� <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> 1 1,1991) S170/TANK (After January 1, 1991) �J' I <br /> V TANK FEE = S50.00/TANK (Prior to Ja Uary n tl� <br /> E 0 Tanks 1986 1987 1988 1989 1990 1991 11992 1993 1994 1995 1996 tnT V <br /> F (multiplY # by fee for J XXXX XXXX c1 <br /> 2( o t� �3q <br /> A each year applicable) /1 <br /> C i <br /> I TANK PENALTY FEES ASSESSED xxxx XXXX <br /> L = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> 1 STATE SURCHARGE <br /> T 1988 through 1990 1991 through 1996 <br /> Y At Tanks. z 556.00 <br /> (Enter amount arzl Year) J /A <br /> / F,( TANK I.D. #(s) <br /> C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) 5 <br /> L # TANK(s)__ X 5234.00 = <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br /> STANK I.D. #(s) - <br /> U TEMPORARY CLOSURE (Plan Review & Ins(xctions) <br /> R S <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours mlinlmlm/FACILITY) 5234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review & COnstructlon Inspections) TANK I.O. #(s) <br /> L <br /> A = S624.00 minimum S <br /> M PLAN CHECK FEE - 578.00/hour (8 hours minimm/FACILITY) <br /> R REPAIR FEE (Workplan Review & Construction Inspections) <br /> TANK LD. #(s) <br /> E S <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimm/TANK) I # TANK(s) __ % 5234.00 = <br /> A S <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br /> R = 5234.00 minimum S <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimam/FACILITY) <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 378.00/hr <br /> S <br /> I <br /> Si = S78.00/hr 5 <br /> CI CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE 5 3 <br /> FOR OFFICE USE ONLY <br /> SUEEPS # COMPUTER # LOC CODE I DIST CODE AMOUNT RECEIVED CHECK #/CASH I RECEIVED St cn <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />