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SAN JOAQUIN COLIN' UBLIC HEALTH SERVICES - ENVIRONMENTAL REAL :IVSIOM <br /> U)DEL4.+AND STORAGE TANK PROGRAN - FEE WORKSHEET ✓ <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I <br /> T licGnf L� /ev; ez <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & �,3v 5 . F/ <br /> CITY / STATE ZIP CODE # of TANKS <br /> A Sia clrD rl �y'�U j at SITE <br /> P <br /> P APPLICANT/BILLING/NAME fvP�iw+lr AA.+�r� APPLICANT CONTACT NAME <br /> ICV e.di f- cc U <br /> C MAILING ADDRESSAPPLICANT PHONE # WITH AREA CODE <br /> A <br /> N C)/.5a ct AU 2 20 ' iz,,v L( - <br /> T CITY STATE ZIP CODE TYPE of APPLICATION " `� ;tl <br /> 5/0 c-k C%} (Closure, Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 1986 1987 1988 1989 1990 <br /> A <br /> C XX l00 s UU <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX <br /> 1 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply T-fee for _ <br /> A each year applicable) <br /> C <br /> I TANK PENALTY FEES ASSESSED XXX% xXxx aj 5 o2QG . <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See CaLifornia H & S Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <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 minimm/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 = S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br /> R REPAIR FEE (workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = s <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 4234.00 minimin $ <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours mininWFACILITY) = $234.00 minimum S <br /> M 20 <br /> TRANSFER FEE = 5 .00 UNAUTHORIZED RELEASE EVALUATION = s78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br /> TOTAL 5 a(,00 <br /> FOR OFFICE USE ONLY <br /> !mn:�u�_:: <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> `!i <br /> c2i - <br /> ...:..........................__..... __" .:::-::::::::......__....._... mean..:_::_....... ............._ <br /> .................._.__...._:............ ... :.. ........:..........._....._._.._. ..__....._...... <br /> ...............e:uev::v_n:::uw::::::uc•••_::uldeviiii'_i4:'m:cz:u!'viv355!!: c=mx_ iiie:i�3::i:i2'.:==i'P ••••••••._— ' <br /> ............................. <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />