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SAN JOAQUIN CON IC HEALTH SERVICES - ENVIRONMENTAL HEAWLOIVSION <br />/OF UlM STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />I <br />1987 <br />11I <br />6 <br />T <br />—C.61� <br />-,I`h' C� �C- <br />FACILITY ADDRESS <br />SITE PHONE 0 with AREA CODE <br />E <br />R <br />& <br />=(X <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br />S <br />S <br />A <br />5234.00 minimum <br />S <br />A <br />CITY <br />STATEI <br />ZIP CODE <br />TA <br />atoSITENKS /7y <br />IC' <br />P <br />vLf <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />I <br />i <br />S <br />I <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE 0 WITH AREA CODE <br />V <br />T <br />CITY <br />STATE ZIP CODE <br />lcf� C'.m <br />TYPE of APPLICATION <br />(Closure, Instattation, etc.) <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />G <br />TOTAL <br />PERMANENT CLOSURE (Removat or Authorized Closure -in -Place) <br />TANK I.D. 1(s) <br />1986 <br />1987 <br />1988 1989 <br />1990 <br />1 <br />A <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I 5 TANK(s) X 5234.00 = <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />TEMPORARY CLOSURE (Ptan Review & Inspections) <br />TANK I.D. x(s) <br />R <br />XXXX <br />=(X <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br />S <br />S <br />A <br />5234.00 minimum <br />S <br />PIPING REPAIR FEE = 578.00/hair (3 hours minimum/FACILITY) = 5234.00 minimum <br />S <br />T <br />FACILITY PENALTY FEES ASSESSED (If Appticabte) <br />XXXX <br />X)= <br />I <br />S <br />I <br />V <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br />0 Tanks = <br />1986 <br />1987 <br />1988 11989 <br />1990 <br />1991 <br />1992 1993 1994 <br />11995 ( 1996 <br />F <br />(multiply A by fee for <br />XXXX <br />XXXX <br />I ! I <br />I <br />S <br />A <br />each year applicable) <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />I <br />S <br />L <br />11 <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T <br />T# <br />Tanks x 556.00 <br />1988 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />S <br />Ci <br />PERMANENT CLOSURE (Removat or Authorized Closure -in -Place) <br />TANK I.D. 1(s) <br />L <br />0 <br />S <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br />I TANK(s) � _ X 5234.00 = S Of <br />A <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I 5 TANK(s) X 5234.00 = <br />U <br />TEMPORARY CLOSURE (Ptan Review & Inspections) <br />TANK I.D. x(s) <br />R <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br />S <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />S <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)) TANK I.D. *(s) <br />L <br />A <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I 5 TANK(s) X 5234.00 = <br />S <br />N <br />PLAN CHECK FEE - 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum <br />S <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.O. *(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I 5 TANK(s) X 5234.00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = 578.00/hair (3 hours minimum/FACILITY) = 5234.00 minimum <br />S <br />N) TRANSFER FEE 2 520.00 <br />Ir <br />CONSULTATION FEE = 578.00/hr <br />FOR OFFICE USE ONLY <br />UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />SAMPLING INSPECTION FEE = 578.00/hr <br />S <br />S <br />TOTAL DUE I S <br />EH 23 032 (REVISED 10-28-93) Page 11 <br />