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SAN JOAQUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL F� OIVSIOM <br /> L s ^O^^'^ STORAGE TANK PROGRAM - FEE UORKSHEE>- <br /> SFACILITY SITE NAME ^ „ ,} FACILITY CONTACT NAME <br /> I <br /> T <br /> EI FACILITY ADDRESS SITE PHONE X ' h AREA CWW <br /> CITY STATSI ZIP CODE # of TANKS / <br /> A ��9� ac SITE <br /> P MVV <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> Sc lay Ce 6oVroir Bid? . <br /> C MAILING ADDRESS I APPLICANT PHONE N WITH AREA CODE <br /> A S c <br /> M <br /> T CITY TATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1 ANNUAL 1986 11987 1 1988 11989 1990 <br /> FACILITY FEE (Prior ;o January 1, 1991) = L100.00 <br /> A V )I)IX)( 1 5 <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX 1 XXXX I S <br /> I <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> x Tanks = 1986 1987 1 1988 1989 1 1990 1991 1992 11993 11994 1995 1996 <br /> F (multiply 7_37-fee for <br /> A each year applicable) 1 %XXX XXXX 1 1 I 10011701 1 S LL7 D <br /> I I I I I <br /> ( TANK PENALTY FEES ASSESSED XXXX %XXX 011701 SSED S <br /> L, <br /> STATE SURCHARGE = 556.00 eacn TANK (Due -very 5 years) See Catifornia H 3 S Cade, Section 25287 <br /> T <br /> Y7(Entr3W_—t%nd <br /> 6.00 1988 through 1990 1991 through 1996 <br /> year) 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. $(a) <br /> L <br /> 0 CLOSURE FEE - 578.001hour (3 hours minimum/TANK) t TANK(S)_ % 5234.00 = S <br /> S <br /> 11 TEMPORARY CLOSURE (Plan Review 3 Inspecti ors) TANK I.D. d(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimum/FACILITY) 1 5234.00 mini mum S <br /> Pj INSTALLATION PLAN CHECK (Plan Review a ConstrUCtioo Inspections) TANK 1.0. M(a) <br /> Ll <br /> A <br /> 91 PLAN CHECK FEE = 578.30/hour (8 hours minimum/FACIL ITY) = 5624.00 minimus 5 <br /> 21 REPAIR FEE (Workplan Review a Construction IrspectlonS) TANK 1.0. 3(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.30/hour (3 hours minimLmVTANK) A TANKS) _ X 5234.00 = 5 <br /> A <br /> 1TANK RETROFIT REPAIR FEE - 578.30/hour (3 hours min./FACILITY) = 5234.00 mini mum S <br /> z <br /> PIPING REPAIR FEE = 578.30/hour (3 hours iinimm/FACILITY) 5234.00 minimum S <br /> NI TRANSFER FEE = 520-00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 5 <br /> I I <br /> Cl CCNSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE - 578.00/hr 5 <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> -WEEPS d COMPUTER = LOC CODE j DIST CODE AMOUNT RECEIVED CHECK 3/CASH 2EC2IVEO 3Y DATE RECEIVED a <br /> EH 23 032 (REVISED 10-23-93) _ _ <br />