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Gro fj <br /> SAN JOAQUINELIC HEALTH SERVICES - ENVIRONMENTAL H DIVSION <br /> U STORAGE TANK PROGRAM - FEE WORKSHEE <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> A CITY \ � STATS ZIP C /I of at SITE <br /> PNKS <br /> L'e C7LT1 v <br /> P APPLICANT/BILLING NAME I APPLICANT CONTACT NAM <br /> C MAILING ADDRESS_ APPLICANT PHONE # WITH AREA CODE <br /> �Vq <br /> 7 (ITT STATE ZI Cqpq TYPE of APPLICATION <br /> (Closure, Installation, etc. <br /> / TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A XX%X XXXX 3 <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX xXXX S <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 # by fee for <br /> A each year applicable) XXXX XXXX S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX I S <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 1988 through 1990 1991 throug .a1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) FED" <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) PQ �;'S4u00�,4 �4 $ <br /> S Ilia <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) �i��JT4 <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) I $234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) <br /> L <br /> A <br /> N) PLAN CHECK FEE = $78.00/hour (8 hours minirtam/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 5234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ D !' <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr <br /> TOTAL DIN: $ [`���c <br /> FOR OFFICE USE ONLYM. <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> « $ 3 <br /> ::::•3:.::««6'iti.:.i'«"3.«...:��i:::...::«�L"..:«t:::::::::::.:L'�."�:::.::_..... �':.i«««J«:"..::.Li....__w«..n.�. ..«..�Lrr.r...�i .«.......i.r........i.«....SC' «I«]«"' <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />