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SAN JOAQUIN C' -T PUBLIC HEALTH SERVICES - ENVIRONMENTAL Hr -H DIVSIGN L GROUND STORAGE TANK PROGRAM - FEE VORKSHEE SI FACILITY SITE NAME • kL 7 I FACILITY CON ACT NAME iI 'c TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum 1 S E FACILITY AOORESS i W C�d*MME LN SITE PHONE N with AREA CCOE ;LZ 3% g�of a I TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S R DIST CODE A CITY y- XXXX STATE ZIP CODE 0 of TANKS I SITE P Ci 1 h� at V PIAPP (CANT/BILLING NAME (After January 1, 1991) APPLICA CON ACT Nr(,L,L�ytA.KW/� %� 571 c "1 EC- k N G I4�J C MAILING ADDRESS 1990 1991 1992 11993 1994 11995 11996 APPLICANT PHONE 4 WITH AREA CODE F O 777 000 T CITY w I I I I I STATE ZIPCODETYPE of APPLICATION Al F P E N C. a1 C /'Y 43�� (Closure, Installation, etc.) TOTAL Cl PERMANENT CLOSURE (Removal or AUthorited Clasure-in-Place) I TANK I.D. r!(s) 2 -'C) 1986 1987 1988 11989 11990 1 I UTEMPORARY R ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 'c TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum 1 S A I XXXX )0= I C TOTAL DUE L 23 OR OFFICE USE ONLY I TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S R DIST CODE T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX I L I = 5234.00 minimum S V TANK FEE = 550.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) E "'an"plY 11986 1987 1988 11989 1990 1991 1992 11993 1994 11995 11996 F a oY fee or XXXX I XXXX I I I I I I I S Al each year applicable) C. I TANK PENALTY FEES ASSESSED I XXXX I XXXX I I I I 5 Li 11 STATE SURCRARGE = 556.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25237 T' Y $ Tanks x 556.00 1988 through 1990 1991 through 1996 (Enter amount and year) f Cl PERMANENT CLOSURE (Removal or AUthorited Clasure-in-Place) I TANK I.D. r!(s) 2 -'C) SI CLOSURE FEE Sib AO/hour (3 hours minimm/TANK) I 9 TANK(s)�_ K 1234.00 I UTEMPORARY R CLOSURE (Plan Revi aw 3 Inspections) TANK I.D. Y(s) 'c TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum 1 RI PLAN CHECK (Plan Review 3 Construction (nspections)I TANK I.D. B(s) iIINSTALLATION E I A P N PLAN CHECK F"c-c = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 mini mm S RI REPAIR FEE ('Jorxplan Review 3 Construction Inspections) I TANK I.O. #(s) E I P TANK LINING REPAIR FEE = 578.00/hour (3 hours miniffuWTANK) 9 TANK(s) X 5234.00 = S A TOTAL DUE L 23 OR OFFICE USE ONLY I TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S R DIST CODE AMOUNT RECEIVED YCHEtx CASH RECEIVED 3Y DATE RECEI nl i 0'417, i SG PIPING REPAIR FEE - 578.00/hour (3 hours minimun/FACILITY) = 5234.00 minimum S NI TRANSFER FEE = 520.00 I UNAUTHORIZED RELEASE EVALUATION - 578.00/hr I S I Cl CONSULTATION FEE - 578.00/hr SAMPLING INSPECTION FEE - 578.00/hr S TOTAL DUE L 23 OR OFFICE USE ONLY SUEEPS ! COMPUTER S LOC CODE DIST CODE AMOUNT RECEIVED YCHEtx CASH RECEIVED 3Y DATE RECEI nl i 0'417, i SG E4 Z3 032 (REVISED 10-28-93) Page 11