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SAN J0AQUIN CUM' 'JBLIC HEALTH SERVICES - ENVIRONMENTAL HEAL IVSION <br /> UNDERU.A= STORAGE TANK PROGRAM - FEE WORKSHEET r ' <br /> S FACILITY SITE NAME G FACILITY CONTACT NAME <br /> I <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> j 616 <br /> CITYc�� STATE ZIP CODE # of TANKS <br /> A S C,�TVYZ� � /_7 q at SITE <br /> P l� l <br /> PAPPLICANT/BILLI G NAME I APPLICANT CONTACT NAME <br /> L �n0 <br /> I <br /> C MAILING AODRESS APPLICANT PHONE # WITH AREA CODE <br /> N �o©� t 5 t `/7 si c 75 - & (03 <br /> T CITYSTATE 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 S <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 # by fee for <br /> A each year applicable) S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX S <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> I - F-- S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/TANK) # TANK(s) X $234.00 = $ <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> Ll I <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br /> R REPAIR FEE (Workplan Review 8 Construction inspections) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 4234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 478.00/hour (3 hours minimum/FACILITY) = 5234.00 mini min $ <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S� <br /> FOR OFFICE USE ONLY _ _ C. <br /> !3_!!!!!!!°!: e!=::::::::::::: v:::::c:...._._....................._. ........T:==..^terF_._3Ti:r..1....^.:..=1C!!!-1!..:......_..:_..:::::::—l _ ..................................:.:........ . _ <br /> .._....._ . <br /> ;.......... ve""v v:.+. vvvfi.miiili!lii�'i!iiicii.riuu'�'i21!N!L]W'u6i" "'""!lilEua!W�:ui!!uiu!4Y'v'" :!v"e:m <br /> SWEEPS # COMPUTER # LOC CODE I DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED is <br /> r+ - <br /> S <br /> .._ 3 <br /> .::..,....F....._...__ :.: � <br /> 'v:::v.3�^�^='-•-xm:-.;..;;c£elle!i!ci`�::-•:!2!i::uwm=teV:r-:-- vua:n,!i3i""a:�51-�"'a:�m--�f l.(�"O •••-• -,n . <br /> EH 23 032 (REVISED 11-1-92) Page 11 e bII li� <br />