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` t SAN JOAQUIN a PUBLIC HEALTH SERVICES - ENVIRMIENTAL HIS DIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAME <br />1986 <br />1987 11988 <br />1989 <br />1990 <br />FACILITY CONTACT NAME <br />I' <br />mill -14 " se neo2e-ren-1 <br />S-Aprr- <br />fan ARSE& <br />r 79 <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />XXXX <br />XXXX I XXXX <br />XXXX <br />XXXX <br />$ XXXXXXXX <br />E <br />FACILITY ADDRESS <br />C <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />SITE PHONE it with AREA CODE <br />& <br />S 0 A <br />R 0A e// <br />S <br />PIPING REPAIR FEE = $78.00/hour (3 hours minim/FACILITY) <br />- -:FS-3 <br />minimum <br />$ <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />I XXXX <br />XXXX I XXXX <br />I XXXX <br />XXXX <br />$ XXXXXXXX <br />CITY <br />Fe;;� <br />ZIP CODE <br /># of TANKS <br />P® <br />/ <br />V <br />TANK FEE = S50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br />%$cZO� <br />at SITE <br />% <br /># Tanks = <br />1987 1988 <br />1989 11990 1991 1992 1993 <br />1994 1995 1996 <br />1997 <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />I <br />a <br />114mee ✓; ,, <br />to 4A l e <br />✓gree <br />S <br />A <br />C <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />N6 <br />0% oen Irte <br />Jc ' <br />D <br />I <br />5,3� — S 6 Q II <br />L <br />T <br />CITY <br />I <br />STATE <br />ZIP CODE <br />TYP f APPLICATION <br />®e C, <br />�° <br />S <br />losure stattation, etc.) <br />TOTAL <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure - in -Place) <br />1986 <br />1987 11988 <br />1989 <br />1990 <br />0 <br />S <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />$ <br />$ a <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />XXXX <br />XXXX I XXXX <br />XXXX <br />XXXX <br />$ XXXXXXXX <br />A <br />P <br />A <br />C <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />$ <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />= 5234.00 <br />minim <br />S <br />PIPING REPAIR FEE = $78.00/hour (3 hours minim/FACILITY) <br />_ $234.00 <br />minimum <br />$ <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />I XXXX <br />XXXX I XXXX <br />I XXXX <br />XXXX <br />$ XXXXXXXX <br />I <br />V <br />TANK FEE = S50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br />E <br /># Tanks = <br />1987 1988 <br />1989 11990 1991 1992 1993 <br />1994 1995 1996 <br />1997 <br />F <br />(multiply # by fee for <br />XXXX XXXX <br />XXXX XXXX XXXX <br />' <br />S <br />A <br />each year applicable) <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX XXXX <br />XXXX XXXX XXXX I <br />I <br />$ <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 <br />is <br />T <br />Y <br /># Tanks x $8.00 <br />1988 through 1990 ($56) 1991 through 1996 (S56) 1997 <br />SURCHARGE FOR 1997 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX <br />$ <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure - in -Place) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />0 <br />S <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = $ . s <br />$ <br />$ a <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />REPAIR FEE (Workp(an Review & Construction Inspections) <br />TANK I.D. <br />#(s) <br />P <br />A <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />$ <br />P <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. <br />#(s) <br />A <br />N <br />PLAN CHECK FEE = S78.00/hour (8 hours minim/FACILITY) <br />= S624.00 <br />minimum <br />$ <br />$ a <br />R <br />E <br />REPAIR FEE (Workp(an Review & Construction Inspections) <br />TANK I.D. <br />#(s) <br />P <br />A <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) <br />X $234.00 = <br />$ <br />I <br />R <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />= 5234.00 <br />minim <br />S <br />PIPING REPAIR FEE = $78.00/hour (3 hours minim/FACILITY) <br />_ $234.00 <br />minimum <br />$ <br />M <br />I <br />TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />$ <br />S <br />C <br />CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr <br />$ <br />TOTAL DUE <br />$ a <br />FOR OFFICE USE ONLY <br />EH 23 032 (REVISED 5-27-97) <br />