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C <br />SAN JOAQUIN IC HEALTH SERVICES - ENVIRONMENTALIVSION <br />TANK I.D. #(s) <br />STORAGE TANK <br />PROGRAM - FEE WORKSHEIW <br />S <br />I <br />FACILITY SITE NAME ®® <br />G'G - <br />S <br />FACILITY CONTACT NAME <br />Zza <br />T <br />TANK I.D. #(s) <br />R <br />E <br />E <br />FACILITY ADDRESS <br />S <br />SITE PHONE # with AREA COD <br />& <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) <br />= $624.00 minimum <br />$ <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />Aat <br />TANK I.D. #(s) <br />P <br />A <br />1=76211 <br />1 <br />SITE 15 <br />S <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= $234.00 minim <br />-ID <br />R <br />P <br />= $234.00 minim <br />S <br />P <br />APPLICANT/BILLING NAME <br />G. <br />APPLICANT CONTACT NAME <br />I— <br />C <br />C <br />N <br />MAILING ADDRPeS <br />APP CANT PHONE # WIT AREA CODE <br />J / 7 / C) <br />T <br />STA E ZIP CODE TYPE of APPLICATION <br />!Cvr <br />v / (Closure, Installation, etc.) <br />TOTAL <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 <br />A <br />S <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (if Applicable) <br />XXXX <br />XXXX <br />$ <br />I <br />V <br />TANK FEE = S50.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br /># Tanks = <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 1991 <br />1992 1993 <br />1994 <br />1995 <br />1996 <br />F <br />(multiply # by fee for <br />S <br />A <br />each year applicable) <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />5 <br />L <br />I <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) <br />See California H & S Code, Section 25287 <br />T <br />Y <br /># Tanks x S56.00 <br />1986 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />5 <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minim/TANK) <br /># TANK(s) X $234.00 = <br />S <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hairs minimum/TANK) <br /># TANK(s) X $234.00 = <br />S <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) <br />= $624.00 minimum <br />$ <br />R <br />E <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />P <br />A <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minim/TANK) <br /># TANK(s) X $234.00 = <br />S <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= $234.00 minim <br />S <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minim <br />S <br />M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br />I <br />S <br />C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr 5 <br />TOTAL DUE <br />FOR OFFICE USE ONLY <br />.............._........._..»«.»...........«....»» « �« .... - «-_..... »...... „, ,: •. _— W::=• ::::•- .. •:�_: _.... ._...! :. .»;.._.»- ::.M.......•-.:: <br />.»....,.'s::: i'a.:::: s....^•?iau'ui?aes?is....:..:. r......................»_:::....»......:»...._s.»..«...«:..«_ '.n'i..« C:::.e=.....R.......».........�....as.....»..«......« ....... <br />::s•..•.=sxa::s:uF=iiiiiiiiiiusnii:es=:ziesmuiiiiEiui:ieiae=iee::tt.�iuFisi`c3ifis:i:u:iii»riiiiaiil� auiHceuEE7hirwiles'=uifi=iiiii'r.==mi6@`r«'—'»°'ttiA's:'ai=:s"riiiiEii?:iiusis« ' �F"isiiii:T=3?uiiiiii3iii£FuF:iziSi.•is"3• Hiiu'rsiliisii••• <br />SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH«_ RECEIVED BY DATE RECEIVED <br />r % 5 ® / / <br />:s <br />Affho-� <br />EH 23 032 (REVISED 11-1-92) Page 11 C` <br />