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®` SAN JOAQUIN PUBLIC HEALTH SERviCES - ENVIRONMENTAL HF4& DIVSION <br />STORAGE TANK PROGRAM - FEE WORKSHEETW <br />S, <br />FACILITY SITE NAME FACILITY CONTACT NAME <br />1 <br />TOTAL <br />T <br />A <br />E <br />FACILITY ADDRESS SITE PHONE # with AREA CODE <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br />b <br />S <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum <br />CITY <br />STATE <br />ZIP CODETait. <br />TANKS <br />Is—, <br />A <br />TANK I.D. #(s) <br />C <br />T <br />SITE <br />R <br />XXXX I XXXX I <br />I <br />S <br />El <br />P <br />5234.00 minimum <br />S <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />5170/SANK (After January <br />1, 1991) <br />I <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />11996 <br />F <br />(multiply x by fee for <br />XXXX I XXXX I I <br />N <br />I <br />S <br />Af <br />each year applicable) <br />TI <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />C <br />I <br />(Closure, Installation, etc.) <br />C1 <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Ptace) <br />I TANK I.D. #(s) <br />TOTAL <br />L <br />A <br />1986 11987 11988 11989 <br />i 1990 <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br />S <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum <br />S <br />UTEMPORARY <br />CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />R <br />XXXX I XXXX I <br />I <br />S <br />El <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />S <br />I <br />V <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />5170/SANK (After January <br />1, 1991) <br />E <br /># Tanks = <br />1986 1987 1988 11989 11990 <br />1991 ( 1992 11993 ( 1994 11995 <br />11996 <br />F <br />(multiply x by fee for <br />XXXX I XXXX I I <br />I I I <br />I <br />S <br />Af <br />each year applicable) <br />C <br />ITANK <br />PENALTY FEES ASSESSED ( XXXX XXXX I <br />( I <br />5 <br />L <br />II <br />STATE SURCHARGE = S56.00 each TANK (Due every 5 years) <br />See California H & S Code, Section Z5287 <br />T <br />Y <br />x Tanks x 556.00 <br />1988 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />S <br />C1 <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Ptace) <br />I TANK I.D. #(s) <br />L <br />L <br />A <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = <br />S <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = <br />S <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum <br />S <br />UTEMPORARY <br />CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />PIPING REPAIR FEE _ '578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />R <br />El <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />S <br />PI <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = <br />S <br />N <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />S <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) ( TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE _ '578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />S <br />N) TRANSFER FEE = 520.00 <br />If <br />CONSULTATION FEE = 378.00/hr <br />;no nFFrm 11qF nNI Y <br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />SAMPLING INSPECTION FEE = S78.00/hr <br />S <br />S <br />TOTAL DUE I S <br />EH 23 032 (REVISED 10-28-93) 3 <br />