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SAN JOAQUIN COUV TBLIC HEALTH SERVICES - ENVIRONMENTAL HEAL )IVSION <br /> IN DEN.wO ND STORAGE TANK PROGRAM - FEE WORKSHEET - <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I <br /> T Mc. M3sZ ,JeCc <br /> E FACILITY ADDRESSI SITE PHONE # with AREA CODE <br /> & 4 3' S � <br /> , 'L � Ci r" C\L <br /> CITY STATE ZIP CODE # of TANKS <br /> AA j }-p IL +-0 G4 C7SZ 05 at SITE <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> V✓�. (.ice VnuS �P c�C:C (a¢— <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N <br /> �! �1/5 4 . C� t, 5 <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> L ocr 4S 2`1J (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to Jamary 1, 1991) = $100.00 <br /> C I W S <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX E 1 O U <br /> I <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 5/ 1986 1987 1988 1989 1990 1991 1992 1993 1994 1 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) ? p S dc <br /> J <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX I XXXX .L - S :>C)U <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 /> mo <br /> (Enter aunt and year) <br /> E <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(S) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = S <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 minimum/TANK) # TANK(s) X $234.00 = $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum 5 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum 5 <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minirmm/FACILITY) = $234.00 minimum 5 <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> 5 <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr 5 <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> ..:::.......................... .._.._............i.�::-:-..........:__' _._.__-__:::,.-�_:-_.-__.........:—::_:_ -'_ _ - ....::...........,.......................:......__....._......._........._..._.._.._...___....___..............:+�_..�._._—._._._. �a:rramtruW�s:><.�rcam` N'r;�".�a`n`''r'.ilii=u_�iiiirmatia;i�:;: i5icsiiy:�iu;w:,siii��i;tiT�iia <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> ...................:..:....:...____...w=—u:ra:_.....__._.er_.._e::n::::::e:a:a:-_:._.._..:—_:an- ._._...o:::e:::e:::... �_:_.::..:: F.i:iiL=ciiii-i_:4- <br /> ......:............�....._. _]iiii3:i_: ':-u�.' "�Je.L'i' '—�dviiu. e..iii.cii—:.=..— ....+tic6:iiuuii'u-:. .:i�ai?iuuuiiiiri6ii..�i:ic_alui_iui='ia <br /> EH 23 03: (REVISED 11-1-92) ` Page 11 <br />