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SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES - ENVIR0 IENTAL HEALTH DIVSIO <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE IORCSIM <br /> I FACILITY SITE NAME FACILITY CONTACT NAME <br /> T M;lcE ,.1 <br /> E FACILITY ADDRESS 16 g 65 SITE PHONE # with AREA CODE <br /> CITY I STATE 21P CODE # of TANKS <br /> Cc,, s7 d& at SITE <br /> IAPPLICANT/BILLING NAME APPLICANT CONTACT MANE'e(G. SO� <br /> C MAILING ADDRESS ` APPLICANT PHONE # WITH AREA CODE <br /> Al2461 20°/ 8 -4Z- <br /> T CITY STATE 55C DEQ TY osMPLICATION <br /> lnstallatim, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 1986 1987 1988 1 1989 1990 <br /> A 7000( 1000( XX10! S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) 3000 I XXX% xxnc S <br /> I <br /> E TANK FEE = 550.00/TANK (Prior to Japery 1,1991) 5170/TANK (After January 1, 1991) <br /> # Tanks 1986 1987 11988 1989 1990 1991 7992 1993 1994 1995 11996 <br /> F (multiply F-Eirfee for <br /> A each year applicable) XXX% %100( ( )000( S <br /> I TANK PENAL <br /> TT FEES ASSESSED )OOIX XXXX I XXXX I S <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California X 8 5 Code, Section 25287 <br /> T <br /> T # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter mnrnt and year) <br /> S <br /> LI PERMANENT CLOSURE v r Authorized Closure-in-Place) TANK I.D. #(s) 0 / Si20 O yS OS <br /> 0CLOSURE FEE = 578.00/hour (3 hours minim %(TANK) # TANK(&) % 5234.00 = 'j.3.�.a <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspection) TANK I.D. #(s) n(/, 015080 <br /> R ---- <br /> El TEMPORARY CLOSURE FEE = 578.00/hour (3 hags niniauNFACI LITY) 5234.00 minimum S � <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N I PLAN CHECK FEE = 578.00/hour (8 hours mininm/FACILIT7) 5624.00 mi ninm S <br /> RI REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P1 TANK LINING REPAIR FEE = 578.00/hour (3 haus minimum/TANK) # TANK(s) % 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimm S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours mininm/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE = 520.00 I UNAl1TUKRIZED RELEASE EVALUATION - 578.00/hr I S <br /> I <br /> C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S Z Q U <br /> -fOR QFF1(_USE-%M <br /> a_ 5-EEP LISTCODETWO-U H IZ-#TCA-SFT-rkECETVEO-B 1`c�ItT-CEUEY <br /> I s = <br /> EH 23 032 (REVISED 4-29-94) Page 11 <br />