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SAN JOAQUIN Cl f PUBLIC HEALTH SERVICES - ENVIRONMENTAL AN DIVSION <br /> UlZMtGRO= STORAGE TANK PROGRAN - FEE WORKSHEET <br /> I FACILITY SITE NAME FACI ITTC014TACT NAME <br /> T6EPCO KN G NSpL i t� 253-334-Z <br /> E FACILITY ADDRESS SITE PHONE # wit AREA <br /> & I-.PSIS& 1 12 C? <br /> CITYS ATE ZIP CODE of TANKS <br /> A Gr G` at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> A MAILING ADDRESS �� APPLICANT PHONE # WITH AREA COU <br /> N , 0 <br /> TrlTYVN*wj\- <br /> le STATE 2IP E . PLICATION <br /> (ll Closur _ Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1986 1987 1988 1989 1990 <br /> A XXXX XXXX )0= $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX =a 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 = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply i#Tfee for <br /> A each year applicable) XXXX XXXX XXXX S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX =O( S <br /> L <br /> I STATE SURCHARGE = S56.00 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 /> $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> O CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S j <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours miniaum/FACILITY) = $624.00 minimum $ <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 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum $ <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE $ uo <br /> ni��:-.: _ _ _ ...__.. _ _.._,•--__,�••••._.---- <br /> �g ti pfdM • ODDIST T' _.WWiT-lffMllVV(b S ��6� 71t1 Tt���ED <br /> T s <br /> $ La <br /> EH 23 032 (REVISED 4-29-94) Page 11 `, 0� 3� <br />