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SAN JOAQUIN COUNTY PURL rAMTR SERVICES - ENVIROMENTAL NEALTN DIVE .3U0 X 3 -z' O <br /> LWERGR000 ';,TORAGE TANK PROGRAM - FEE WORKSHEET - -z S <br /> SI t CILITY SITE NAME FACILE-T/,Y�CONTACT NAME <br /> � <br /> I S C �T< P"+ �C. <br /> 1 .. <br /> t_ IAL'ILITY ADDRESS SITE PHONE f with AREA CODE <br /> ASTA111 C.;1 TE YLZ / at $ITENKic� -K-S Z-f�v O 's#• � <br /> P APPLICANT/SIL UNG NAME APP ICAM� OptTACT ME <br /> I <br /> I _... <br /> Tr. NA IMGADO SS C_� APPLICANT NONE- -0WITH AREA CODE <br /> xaaN _ ... u cf 333 <br /> I CI IT TE IP =1 TYPE of APPLICATION - <br /> _ —ZU (Cloture, Installation, etc.) <br /> TOTAL <br /> 1986 1917 1916 1969 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) a $100.00 y-;- <br /> A /UO ✓OD l0 (,� f 500 <br /> I FACILITY PENALTY FEES ASSESSED (if Applicable) XXXX xxxx /Q(� O ) Qd f 3 d Q <br /> 1 -- <br /> V TANK FEE • (50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E -- <br /> t Tanks 1986 1987 I 1908 I 1969 1990 1991 I 1992 1993 1994 1 1993 1 1996 <br /> F (multiply N by ha for <br /> A each year applicable) 1S(- 1S / tsvl- ./7_-10 510 s _ D <br /> C__ <br /> I LANK PENALTY FEES ASSESSED %XX% %X%)I �SQ ,�Q s s� S/If L/ <br /> I <br /> I STATE SURCHARGE • $56.00 each TANK (Due every S years) Sea California N 8 S Coda, Section 25207 - -+- <br /> I <br /> T a tanks x $56.00 1986 through 1990 1991 through 19% _ <br /> (Enter amount and Year) DD ! / �' ?- <br /> (� <br /> C PERMANENT CLOSURE (Removal or AuthoriZOd Closure-in-Place) TANK I.D. #(a) <br /> I _- <br /> 0 CLOSUeE FEE • S78.00/hour (3 hours minlasWTANK) 0 TANK(s) X 8234.00 ■ " 70,2- 0,0 <br /> S ---- <br /> U IEMPORART CLOSURE (Plan Review f Impectlatn) TANK I.D. Va) <br /> E TEMPORARY CLOSURE FEE • {78.00/hour (3 hours minima/TANK) E TANK(s) X $234.00 • S <br /> P INSTALLATION PLAN CHECK (Plan Review A Construction Inspections) TANK I.D. IM <br /> N PLAN CHECK FEE • $70.00/hour IN hours adnlassa/FACIIITY) • (624.00 minimum <br /> R REPAIR FIR (Workplan Review S CN»truetlon Inspaat NLN) TANK I.D. 00) <br /> P fANK LINING REPAIR FEE • (70.00/how (3 hours minimum/TANK) S TANKW _ X $234.00 • �S <br /> .A --- <br /> I TANK RETROFIT REPAIR FEE • $78.00/hour (3 hours min./FACILITY) • $234.00 minim S <br /> PIPING 49PAIN Fit a 678.00/haw (3 hours minima/FACILITY) • $234.00 ■inlan S <br /> N TRAMSFER FEE • $20.00 UNAUTHORIZED RELEASE EVALUATION • $78.00/hr i <br /> I . <br /> S - <br /> C CONSULTATION FEE • $78.00/hr SAMPLING INSPECTION fit • 178.00/hr f -,r. . <br /> -- TOTAL DIE <br /> 'V OFFICE USE OMLT Tam E „• <br /> "li's- 'tivll'EI IYCYitlml!' anYL°t'au"in a <br /> .WY LiIimLYY6' Biel" a+ y.�'. <br /> ,LEEPs 9 C(NIPUTER a LOC CODE DIST CODE AMOUNT RECEIVED CHECK <br /> r'.,a:m.ms�mr3ue�mwi3 <br /> W02,112 <br /> a/CASH DECEIVED BY DATE <br /> D <br /> 3 <br /> W0 , 12 <br /> F! <br /> FM 15 032 (REVISED 11-1-92) Page 11 <br /> r <br /> '9C <br />