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SAN JOAQUINtl DIC HEALTH SERVICES - ENVIRONMENTAL HE�IVSION <br /> U STORAGE TANK PROGRAM - FEE WORKSHEET <br /> 'SFACILITY SITE NAME FACILITY CONTACT N <br /> T <br /> E FACILITY ADDRESS SITE PHONE w th EA CODE <br /> & s �q- �"-z-,71 <br /> CITY STATE ZIP COD' <br /> # of TANKS <br /> A C at SITE <br /> P <br /> P APPLICANT/BILLING N E APP 1CANT CON T NAME <br /> I <br /> C MAILING ADQ@FSS �O APPLICANT PHONE # WITH AREA CODE <br /> N <br /> T CITY <br /> A \ <br /> STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 <br /> A xxxx xxxx xxxx XXXX S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If App(icable) xxxx xxxx xxxx xxxx S <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 7986 1987 1988 7989 1990 1991 7992 1993 1994 1995 1996 <br /> # <br /> F (multiply by fee for <br /> A each year applicable) xxxx xxxx xxxx xxxx $ <br /> G <br /> I TANK PENALTY FEES ASSESSED XXXx xxxx vxx xxxx S <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California X & 5 Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1988 through 7990 7991 through 1996 <br /> r) <br /> (Enter amount and yea <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.O. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /> # TANK(s) X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (P(an Review & Inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br /> R REPAIR 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 8234.00 = E <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = 8734.00 minimum S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE = E78.00/hr SAMPLING INSPECTION FEE = 578.00/hr E <br /> TOTAL DUE E <br /> FOR OFFICE USE ONLY <br /> ma— <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> = S <br /> EH 23 032 (REVISED 4-6-95) • <br /> • <br />