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SAN JOAQUIN G f PUBLIC HEALTH SERVICES - ENVIRONMENTAL I. H DIVSION <br /> UNL,tRGROUND STORAGE TANK PROGRAM - FEE WORKSHEET _ <br /> I FACILIT SII 'E NAME FACILITY CONTACT NAME <br /> T Lel— J <br /> E FACILITY ADDRESS (JOR��ttJ SIT PH with AREA CODE J <br /> & CITYO I 1 ATE ZIP CODE TANKS <br /> A COV #205 at of SITE <br /> P <br /> P APPLICANT/BILLING NAM APPLICANT CONTACT NAM NC <br /> L <br /> I <br /> A MAILING A DR SS I � ���O� APPLI � POH NE # WITH AREA CODE <br /> N U � <br /> T CITY STATE P C E ICATION <br /> JE!��PL <br /> Insta(lation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 _ <br /> A XXXX XXXX $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX $ <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # yfee for <br /> A each year applicable) XXXX XXXX $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX $ <br /> L <br /> I STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) 2 �[(q-1 014; <br /> L <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <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 /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimus $ <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> S $ <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr <br /> TOTAL DUE $ q%j <br /> ONLY ..........................................................._...........:::::::::::::::::::::::::-:-::::::-:::::::::::::::::::.--:::::::::::-: : ::::::::::-::::::¢=.s;::::-.=.sa:atss:s:a::a¢t::t <br /> FOR OFFIC USE....................................._................................• ::................................................................................... <br /> .... .... <br /> ..................................... _.......................... . . V D <br /> :: SWEEPS # COMPUTER #��� � LOC COD���� DIS1'•��OD���•� �AMOUNI'� RECEIVED CHECI( #�/CASA REC(_IVOD BV (SATS R C I E <br /> ............................................... . . <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />