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SAN JOAQUIN COU'" LIC HEALTH SERVICES - ENVIRONMENTAL IIEA'*VSICdI <br /> UNL rOND STORAGE TANK PROGRAM - FEE WORKSHEET r j <br /> ( SITE NAME 1 FACILITY CONTACT N !9 <br /> ILITY ADDRESS _ SITE PHONE Al with AREA CODE <br /> o <br /> CITY STAtjE ZIP CO(") # of TANKS <br /> — — ( . G?,, i• /�- at SITE <br /> P <br /> P APPLICANT/BILLING NAME APP 1CANT CONTACT NAME <br /> I <br /> C MAILING ADPRESS APPLICANT PHONE U WITH AREA CODE <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 7987 1988 7989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A %%XX XXXX XXXX XXXX $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %XXX %X%X XXXX XXXX 3 <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) 3170/TANK (After January 1, 1991) <br /> E <br /> 4 Tanks = 1986 11987 1988 1989 1990 1991 1992 1993 1994 11995 1996 <br /> EPENALTY <br /> # by fee for <br /> applicable) XXXX XXXX X%XX %XXX $ <br /> LTY FEES ASSESSED %XXX XXXX XXXXXX%% 3 <br /> RCHARGE _ $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> x 556.00 1988 through 1990 1991 through 1996 <br /> mount and year) -- <br /> C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK E.D. #(S)_--- <br /> L <br /> (s) ___L <br /> o CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> EI TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #<s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ <br /> RREPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = 3 <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 _ $78.00/hour (3 hours mini mum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = 378-00/hr S <br /> I <br /> S1 I <br /> L CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr S <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC LODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> 3 <br /> 3 S <br /> _- <br /> L„T��=_..—__. __._�___.__.._-mem= 1T <br /> EH 23 032 (REVISED 4-6-95) <br />