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SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRO WMMK WORKSHEET DIVStON <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE <br /> FACILITY FAC CONTACT NAME <br /> 5 SITE NAME <br /> I <br /> T SITE PHONE M with AREA CODE <br /> E FACILITY ADDREnL,Cl._ <br /> R ST E 21P CODE N of TANKS <br /> CITYet SITE <br /> A <br /> -` may 1 U APPLICANT CONTACT NAME <br /> P APPLICANTlBILLING NAME <br /> AP LIC NT PHONE fl LII H AREA CODE <br /> C MAILINGORE55 <br /> A <br /> N ST TE TIP CODE <br /> CITY _ TYPE of APPLICATION <br /> T 'A� --/)/ (Closure, installation, etc.) <br /> Cfl <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ %100.00 <br /> xxxx xxxx <br /> A f <br /> C xxxx xxxx <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) <br /> I $170/TANK (After January 1, 1991) <br /> V TANK FEE ■ $50.00/TANK (Prior to January 1,1991) <br /> E 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> 0 Tanks % <br /> F (multiply N by fee for xX%X xxxx <br /> A each year applicable) <br /> f <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx <br /> L 556.00 each TANK (Due every 5 years) See California H b S Code, Section 25287 <br /> 1 STATE SURCHARGE <br /> T1980 through 1990 1991 through 1996 <br /> Y N Tanks x %56.00 <br /> (Enter mount and year) f <br /> C PERMANENT CLOSURE (Removat or Authorized Closure-in-Ptsce) <br /> TANK I.D. N(s) <br /> L N TANK(s) X t234.00 <br /> 0 CLOSURE FEE _ $7g.00/hour (3 hours miniaxm/TANK) <br /> S TANK I.D. N(s) <br /> U TEMPORARY CLOSURE (Plan Review L Inspections) f <br /> R N TANK(s) x $234.00 = <br /> E TEMPORARY CLOSURE FEE _ %78.00lhour (3 hours minim.sa/TANK) <br /> P INSTALLATION PLAN CHECK (Pion Review i Construction Inspections) YANK I.D. N(a) <br /> L f <br /> A <br /> N PLAN CHECK FEE f78.00/hour (8 hours minimus/FACILITY) %624.00 minimum <br /> TANK I.D. N(s) <br /> R REPAIR FEE (Llorkpion Review E1, Construction Inspections) f <br /> E X $234.00 = <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minieemlTANK) N TANK(s) $ <br /> A ■ S234.00 minimum <br /> I TANK RETROFIT REPAIR FEE ■ $78.00/hour (3 hours min./FACILITY) $ <br /> R ■ $234.00 minimae <br /> PIPING REPAIR FEE ■ 578.00/hour (3 hours ministLnn/FACILITY) <br /> N TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION <br /> Es7j5.00jHhr SAMPLING [NSPEOTION FEE <br /> C CONSULTATION FEE = 178.00/hr TOTAEqEj <br /> i <br /> r rr <br /> .nutekllm?ue <br /> .= n!t}{!!gnu!me!!::1!r.!!!=.!!{Em!r,!e!�m!^nn!u!!!!!r!!!a!n�rgt!!!I?!mnmin!u!tri!!!!nn'aFsiiislii�iuiiiiii'iiii uiiiiiii�lu�i uii uiriiiiktitk!#t!!tlau! <br /> FOR OFFICE USE 016LY <br /> DATE RECEIVED <br /> r1!i,ii.il}srh e.is{.{?.i{i'!##I:!i7lllillll!i!'Il 14Jlllsi!!i!}l Illl!i 4ii}i4!!!"si!#}it{}tlll;Iii{i?'.iillilllllElll!111111!r!?{E}ii!t#i1!.{{{IlHI1E3SB{!IE!?i.i6EElEli. <br /> 1!II <br /> SWEEPS M COMPUTER N LOC COOS DIST CODE AMOU►II RECEIVED CIiECK NICASH RECEIVED 9Y <br /> — <br /> v! f ' '!!IIII!III!II10111lIi!gq}t!!!li#?{!EC!illtlt'1!l!'.lf!S#k '.IIIIIIH pll lllll![4i}'!I!!!1!!I"N!sll!111�rytjIIIIIIIII!@l!!!!#!!!#!!S!f#mk k41111i11!Rlliltl�li!I!!!iFi <br /> y 1!11?1NIlIaI!Iili'!IPI!Itlli 111 11}li!Illl!I!I#H!I;IS!illlllll!I.1111!' LUIgI'I'.= �! I II <br /> tiEilill!.!ii'.I!EII Inl�lil!!t!}f}k�}3�I!iii!{!i!t#'.!!3!{i!i!i??TIIII s <br /> !�#iil!tilllil!Lis!!��tlllll!illlElll! 11611�1IIItliIIIEIIIIIIIIIIIHIIIIIIIIIItlII11IlIIllGtlipillllllllllllE llll�llllklilk!IRI!i1i11111111iIIIIIIIIIIIIILII!f1tliJlllll.IIIIIilllllil{IIIIIIIi{}!lilli!lililhliliUlllSll44#I##iL'ii!i!!!#IIIII!1!##i#i###I II!Ill kkfllll#11111111#UII!!IIIIIill11 1!11iHll#IlllilH Illll#HIHIIir. 11!!!lkIHIIAI#IIILII!IIIIII <br /> eu ix nit %REVISED 6-21-93) Page 11 <br />