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SAN JOAQUIN COR(Ty PUHLIC HEALTH SERVICES - ENVI r' <br /> ERGRCIAO STOtUfF TANK PfiO7tAN RONIENTAL NEI OIYS ION <br /> FEE WORKSHEET' <br /> S FACILITY SITE NAME %/O n sr*+ ? eLe. FACILITY CONTACT NAAE <br /> T / ' �� C/(-,) <br /> .9 Gra <br /> E FACILITY ADDRESS SITE PHONE it with AR <br /> A <br /> CITY STAT ZIP CODE K o ANK <br /> s�o �vY G� <br /> P- at 5 <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT N <br /> FCC.lLG ".ti, /¢ <br /> C MAILING ADDRESS <br /> A AP LIGNT PHONE R WITH AREA CODE <br /> N Sov <br /> T CITY � STATE ZIP CODE TYPE of APPLICATION /J <br /> v // <br /> S A)'I C, Y (Closure, Installation, etc.) <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100 1986 1987 1988 1989 1990 <br /> .00 <br /> A <br /> G /U /CJD- /W S - <br /> T FACILITY PENALTY FEES ASSESSED (If Appli[able) )COO X%)O 1/00- /c0-}lo S--300 -- <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> p Tanks = 1986 1987 1988 1 1989 1 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply At by fee for <br /> C each year applicable) - -- O .SD 7U /7U /7U t <br /> � . <br /> [ TANK PENALTY FEES ASSESSED %XXX XXXX Saj 5`Q �7 170 `70 /701 S /. <br /> L / <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y X TanksL z 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> 5 <br /> CPERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.O. x(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 - S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(a) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/TANK) 1 TANK(s) X 5234.00 - 5 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. x(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimun/FACILITY) = $624.00 minimia S <br /> RI REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. N(a) <br /> E <br /> P TANK LINING REPAIR FEE - 578.00/hour (3 hours minimum/TANK) K TANK(s) X 5234.00 S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 mini mm S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 mini mun S <br /> NTRANSFER FEE = $20.00 UNAUTHORIZED RELEASE -EVALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING <br /> —INSPECTION FEE • 578.00/hr 5 3A <br /> TOTAL DUE s 33�. <br /> FOR OFFICE USE ONLY <br /> SWEEPS $ COMPUTER % LOC CODE DIST CODE AMOUNT RECEIVED CHECK $/GSH RECEIVED 8Y DATE RECEIVED a <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />