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h <br /> SAN JOAQUINIC HEALTH SERVICES - ENVIRONMENTAL k DIVSION <br /> AND STORAGE TANK PROGRAM - FEE WORKSHEETT <br /> S FACILI SITE NAME FACILITY CONTACT NAME <br /> I <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> CITY STATE ZIP CODE # of TANKS <br /> AfI at SITE <br /> P— 61 <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 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 XXXX XXXX E <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX 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 # y fee for <br /> A each year applicable) XXXX )XXX j 7 S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX 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 through 1996 <br /> (Enter amount and year) <br /> Sta <br />. 5 <br /> CPERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minima/TANK) # TANK(s) X $234.00 = 5 <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 minim/FACILITY) $234.00 minim 5 <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 minimum/FACILITY) = S624.00 minim S <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 $234.00 = $ ' <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 minim S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minim S <br /> N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr $ <br /> TOTAL DUE 5 <br /> FOR OFFICE USE ONLY <br /> _--:«.-::: •:-.»«-ssas«««:::.--:sr.«.•�:::-«x«:«-.. __.... .»..:.. .':�:::finm-::::».•«::««:««s.--s«:::::::w-«::««M•«-.-.•:::,:; ..... ......... ........:«::::«mss._ <br /> ««_...._»_ «...._..._..._...........«_........._•.:......:......:.»..». .....: .......:::-._....».:•:- ..»...«..._..«.... .............._...�:::...:«:.»...:.._._ ; _.: <br /> .«.....«...:r•«.. tt««::••�•« ;...:•..:.«-:::«....»..;i.....«.. rr..:......:..:• ss.:as. :rn»s....r......•x•..�....i.. «.^-„r:••..�..........;«...i..«:•:^s•... «.............;:iee ....««..«..... <br /> «. <br /> .••.»••••.••;••z'�s''«sa:s.. .i?:? .:EEE....E...9C«ss�:tee_«s........a..«....«.::..»:.:::.e•.'"••• •:•••;•••••••.^..i.s'::«Gs...:.s..s.•':fiS::sk.'•�t3:a:::£::•H4?s3i°iii�?i!RMii:.—s: •::•"'«« <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED M CHECK #/CASH RECEIVED BY DATE RECEIVED M <br /> :«::« ^ ^......•^^..:::C::«::..^...^.:::.....�««.......».««...«.....:!«::i:::«:«:i«:^.::::.:««.. .«a ..«.»...........»...........................»........:•::«::«::::.�:««:..."'...^«.. ..........::«:«:::]«:: <br /> .... ........................................._.«...r...»«..................._........._.»..«..«.......... ..........................«....... .:«............. .......... ..........._..........................«............«. <br /> «:?::r.:c«:::«::»»««: :«:««:»::::::««::«:«::« .« «.:«.•......:::• •:.:::::::»::«:«:»«u:::::.s....s..fsr.:.s.........................«.»_.:..........:..»»»_»...s...w..a. ».—;::.a:.^.r.::.•:::rc«:::««::::::::«««:::::::«»::««:««o::sssn3F«:«E«ia:e:«::•�:«?:L�::r.«:-aa <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />