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SAN JOADUIN CMUM PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> GROUND STORAGE TANK PROGRAM - FEE WRKSHE_='" <br /> i <br /> S FACI LIT) SITE NAME q [ 7— FAC TT C JW( <br /> I 5)W0_ a(.i' l � (nLt'W` 7171/V�.T[ ' <br /> SITE PHONE # with AREA CmES��� <br /> E FACILITY ADDRESS <br /> 6 � / 5y <br /> & CITY ,_I IP CODE # of TANKS <br /> A _ �q a3 at SITE <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILL ING NAME ! <br /> L 011 <br /> I <br /> C MAILING ADDRESS APP ICAHT P ONE # WITH EA CODE <br /> A ) Jo CQ <br /> ^ �, - <br /> I <br /> T CITY ] , SA -I ZIP��E TYPE of APPLICATION <br /> L1�1/v 11/./1 (Closure, Installation, etc_) <br /> TOTAL <br /> 1986 17987 11988 1989 7990 <br /> ANNUAL FACILli( FEE (Prior to January 7, 1991) = 5100.00 XXXX A1X% I X =xx I =xx S rm=om=x <br /> A <br /> CXXXX I XXXX I X.(X.Y =aI D00( S XX xx <br /> T FACILITY PENALTY FEES ASSESSED (If AppLimbLe) <br /> II 5170/7ANK (After January 1, 1991) <br /> V TANK FEE = 550.00/7ANK CPrior to January 1,1991) <br /> E <br /> : 'anxs 1 7986 1987 7988 11989 1990 11991 1 1992 11993 1995 1995 1996 <br /> FI (multiply ", by fee for <br /> A+ each year a=LicaoLe) X)= )0= =C( )COCK I X,XXY <br /> !I TANK oENALi1" FEES ASSESSED I XXXX -z= I xxn I X)= XXX" I I ! I S <br /> I STATE SURCHARGE = 556.00 eaci TANK (Due every 5 years) See Ca li fonia H & S Code, Section Z5287 <br /> 7 1991 through 1996 <br /> 7 Tanks_ x 556.00 1988 through 1990 °"9 <br /> (Enter amount and year) I S <br /> CC!OSJRE (Removal or Authorized Closure-in-PLace) TANK T.D. #(S) <br /> LTANK(sl X 5235.00 = S <br /> O CLOSURE FEE = 378.00/hour (3 hours mnimum/TANK) <br /> UITEMPORARY C'CSURE (Plan Review S lrspecti ors) TANK I.D. #(s) <br /> _R S <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours mininn+n/FACi!Ii,) 5235.O0 mini PAm <br /> PI INSTALLATION PLAN CHECK (Plan Review & :a traction ImcectioVG)I TANK I.O. #(s) <br /> L <br /> AIS <br /> NI PIAN CHECK FEE = S78.00/hour (8 hours minimLmVFACILI TY) = S625.00 minimus <br /> i <br /> RI REPAIR FEE (Vorkolan Review & ConsUZStim Inspections) I TANK I.D. #(s) <br /> E S <br /> p TANK LINING REPAIR FEE = 578.00/hour (3 hours minim /TANK) = TANK(S) X SZ35.00 = <br /> AS <br /> I TANK RETROF iT RE°AIR F'c = 578.00/hour (3 hours min./FACILITY) = 3235.00 minimum <br /> R SZ35.00 minimm I S <br /> DIP!NG REPAIR Few = 278.00/hour (3 hours minimJm/FACSLtTf) = <br /> M TRANSFER r'cE = 520.00 UNAUTHORIZED RELEASE EVALUATION = S7a.00/hr I I I S <br /> I I I <br /> SS <br /> C CONSULTATION F_ = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br /> TOTAL DUE 3 Z <br /> FOR OFFICE USE ONLT - - <br /> SWEEaS CDMPUTE'n ( LOC CODE DIST CODE i AMOUNT RE=-;VED CHECK -/CASH RECEIVED 37 DATE RE=VED <br /> s--= <br /> 13 — <br />