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s <br /> SAN JOAQUIN CCt4TY PUBLIC NEALTN SERVICES - ENVIRONMENTAL HEALTH DIV$FON <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE UORKSHEET <br /> ITT SITE NAME FACILE CONTACT NAME <br /> � <br /> ACILI Ir A00RES5 SITE PHONE $ with AREA CODE <br /> (6 !f ( c5 z01 - CI-6 <br /> ti <br /> Tel lip COD1 a of TANKS Z- ISO o O #i <br /> at SII! <br /> APPLICA T/BIL ING NAME APP ICANCONTACT a <br /> v-G ,eGO 17a1' <br /> Hnt`ING ADD SSS APPLICANT PHONE,1 WITH AREA CODE <br /> if(,/ J3�s <br /> I:IIY TE IP CODE TYPO of APPLICATION <br /> (Cloture, Installation, otc.)Z411 I.6e— <br /> TOTAL <br /> 1966 1967 19M 1969 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) • $100.00 <br /> F ACILIIY PENALTY FEES ASSESSED (if Applicable) <br /> FAHK FEE fSO.00/TANK (Prior to Jsnuary 1.1991) 5170/TANK (After January 1, 199$) <br /> Y Tanks 1986 1987 1988 1989 1990 )991 I W9a 1993 1 1994 IWs 1996 ::.•. <br /> (naatiply N by fee for t <br /> T Inch year applicable) <br /> I TANK PENALTY FEES ASSESSED XXXX %XXX $ . 4 <br /> I STATE SURCHARGE • $56.00 each TANK (Dua wary s year$) See California N { t Code, Section 25287 , .�l,V, <br /> r tl fenka A $56.00 1986 t39 <br /> hrouah 1990 1991 throuIph 1996 <br /> (Enter wnovrt and Yeer) $ .,_ <br /> C PERMANENT CLOSURE (Removal or Authorized Closurs-in-Plect) TANK I.D. 1(a) <br /> o CLOSURE FEE $78.00/hour (7 haunt' winlnas/iANK) 1 iANK($) X $234.00 �k.3 <br /> $ _ . <br /> TI TEMPORARY CLOSURE (Plan Review { tMpeetloFs) TANK I.D. !($) <br /> I TEMPORARY CLOSURE FEE • {76.00/hour (3 hours wlntaeas/TANK) 8 TANK(*)_ X $234.00 • f <br /> n r.: <br /> P INSTALLATION PLAN CHECK (Plan Review { Construction IMPactIOM) TANK I.D. f(a) a j• <br /> 1 — <br /> ^ . $624.00 minimum <br /> $ <br /> N PIAN CHECK FEE • $78.00/hour (6 hours wlnllwaTJFACILITY) r <- <br /> N REPAIR FIR (Vorkplan Review { Conatruotlen Ins1*1e11001$) tAMK 1.0. tltq ". <br /> I- IAIIK LINING REPAIR FEE • S78.00/hour 0 hours wtnimua/TANK) / TAMK(e) % $234.00 • �$ <br /> • $234.00 mini" <br /> $ <br /> I IAIIK RET0.0flf REPAIR FEE $76.00/hour U hours win./FACILITY) <br /> R __IPI a $234.00 minimum S <br /> I•IPIuO AroA1R 1[l • !76.00/hour l7 hours wlnlsAayMCILI7T) <br /> .M TRANSFER FEE • $20.00 [UNEAUTHORIZE01PRELEASE EVALUATION • $76.00/hrC1:ONSUL IATION FEE • f78.00/hr TION FEE a $18.00/hr, <br /> ... .._. TOTAL DUE IT <br /> Q OFFICE USE ONLY <br /> ..I.EEPS tl c COMPUTER ! LOC CODE DIST CODE ANd)NI SECEIVEO CXECK //CASH RECEIVED SY DATE IVEO , <br /> 01 !I 032 (REVISED 11.1-92) h$e 11 i �� , - Lr,Ua <br /> s�SI <br />