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SAN JOAQUIN * " PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEAfiLH DIVSION <br /> STORAGE TANK PQOGRAM - FEE WORKSHEE <br /> SFACILI SITE NAME FACILITY CONTACT NAME <br /> I � <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> b <br /> CITY STATE ZIP CODE # of TANKS <br /> A at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE FTYPEf APPLICATION <br /> re, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX f <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX S <br /> 1 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E •-� <br /> 0 Tanks = _(— 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 7c�iJ�F��bblpD <br /> F (multiply # y fee for <br /> A each year applicable) XXXX XXXX 170 S 0 <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX 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 /> T # Tanks I x $56.00 1988 through 1990 1991 through 1996 Tj.IV#F DI bb1po <br />+ (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) 8r 7 <br /> L p <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S"3 <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) $234.00 minimus E <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L -- <br /> a 00 <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) <br /> TANK I.D. #(s) <br /> , <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./FACILtiY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimus S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S b <br /> FOR OFFICE USE ONLY <br /> :r... r..tt.me:te:r»»::r.:tt:n:t.•ttt:nt:msmt:nr:s+::tnrtr:t}-sn::£::£:£??!£d£}?Fi?dm}}}£did!dii!!!d?££n};t, ..:r.:::et:}:ii?ie'!£:+n:i?"•}id!£!}:dFEE£'tt!iisi£££ii d£d£££dddddd8iidd�d£i£!£}}nm+}}33d?d!££ii££}£i}d3!!dddiddd£!d!!!!iidid£dmd£!!dE!}d}!!f}}}!di!!E!!i!'.d <br /> dd......tt"'+i:.'ddmdd?ft...i:...?i...:::....»........£E......................:•::::.»..t::a...•.. ... ..... ............ .....r.. .. <br /> MM rr:•:•r••a•-m a....a+.1 s.,;.:its Piia?:EiiE:!§su?ddNddidildidi33d m IUld££££ !.di?33£d!i33Gtdaid!id!!id!Lt'tdr�?}?£?dEEi':31 <br /> 3....»Ls.3i.idMidd3a.i?31133.Ei.ttiili..a .t.ta.m.a£......t.li....i..n..i..et3..a t R. t. <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT ReC71 VED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> • .......-_»».—;••.:. •..••» :»r:ttr...tt::+r:n tt:ne:::tt:estt+::.......... . ..:r.:m:::r: . n^:•: . -::e:......m:.rc:tt::::r•:•tn . mtt:::-::: ..:••+:::mr::e:m:a:::ers•:ttertr::rtne::^:::::ra:... <br /> ... -n. 1 m .n.es......tt.....r.............+.........:}nr}t}tco.e:.:.................£........d...........::i...t..........+t...............:.i+£..»3.....id£d..:+..t.i....................................................ddd!!i„.»..............d E:............+.......a......»...............» <br /> ............._.............................................»...........................................................................................»... ......!H.......... ............. ......... <br /> ».»........... ..................................................................... r........s...:....s..»....s........... .... <br /> am::FL•n:[£isu::!:?::::?:s:::::?::: ::::::::::r.::::r::r.+x::::.a:.:...e....::._........ .......a....t..i».»us+a.....:...a...it............sa.....,.......Ldd:.........:...:.t......:......:..s.......a..f....... ..s.:sEiu.....s............:..................»..t.........».:...sE.»t.»._.»..::s.+s:...sss.................t <br /> EH 23 032 (REVISED 10-28-93) Page 11 ' <br />