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SAN JOAOUIN CCtKff PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE Y - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> CITY STATEI ZIP CODE at SITENKS <br /> C.A G 52-1 4f <br /> APPLICANT/BILLING NAME APPLICANT CONTACT <br /> a.'4- sca L.c, <br /> ' HAILING ADORE SS APPLICANT PHONE # WITH AREA CODE <br /> 2'K Yo C 41 to 2-."L41-! <br /> CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1986 1987 1988 1989 1990 <br /> XXXXwx =cxI S <br /> FACILITY PENALTY FEES ASSESSED (If Applicable) S <br /> ! TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 19WI 1989 1990 1991 11992 1993 1994 19M9511996 <br /> F (multiply fee for <br /> A each year applicable) XXXX )0= S <br /> I TANK PENALTY FEES ASSESSED I XXXX XXXX I I I I S <br /> i STATE SURCHARGE a S56.00 each TANK (Dee every 5 years) See California H & S Code, Section 25287 <br /> t # Tanks x $56.00 1986 through 1990 1991 th rough 1996 <br /> (Enter t and year) <br /> 7 Z7 <br /> S <br /> PERMANENT CLOSUREeuava or Authorized Closure-in-Ptace) TANK I.D. #(s) rte- �-.v,ter J° i/ S" <br /> L <br /> 31 CLOSURE FEE a 578.00/hoar (3 hours minimum/TANK) # TANK(s)-,a _ X 5234.00 = S v '7- <br /> S S <br /> Ui TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE a 578.00/hoar (3 hours minimum/FACILITY) 5234.00 minim S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (B hours minimum/FACILITY) = $624.00 minimum S <br /> E REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) _ <br /> P TANK LINING REPAIR FEE a 578.00/hour (3 hours minim/TANK) # TANK(s) X $234.00 = S _ <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum 5 <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours mini FACILITY) a S234.00 minim S <br /> I TRANSFER FEE a $20.00 I UNAUTHORIZED RELEASE EVALUATION = S7B.00/hr I I S <br /> C CONSULTATION FEE a S78.00/hr I I SAMPLING INSPECTION FEE = S78.00/hr I ( S <br /> TOTAL ME S 3 2(' <br /> FOR 0 . <br /> SW U Em Bill CODEaMou ( CAH RECEIVED 19 SAM KC6Z1VCMN <br /> i s I i g <br /> EH 23 032 (REVISED 4-29-94) Page 11 <br />