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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIV7011111 <br /> SION Q� <br /> 61 'ERGROUMD STORAGE TANK PROGRAM - FEE wORKSHF"' k <br /> S FACILITY SITE NAME FACILITY ACT NAME <br /> I GKNo, 1�od �3hrrwu-ovu tl'hC� <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> a <br /> CITY ) _ STATE ZIP CODE # of TANKS <br /> A ✓..{_LJA-_�"...`.'� at SITE 3/3 <br /> P <br /> APPL[CANT/BILLING NAME APPLICANT CON AC�)AII� _ -� eS r <br /> L - _ - __ <br /> I <br /> AMAILING ADDRES 60 / - I / APPLICANT PHONE # VITH AREA CODE <br /> N N <br /> CITY G�/ STATE 2 P E TYPE ur APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX XXXX XXXX S XXXXxxXxXxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %XXX XXXX Xxxx xxxx XXXX S xxxxxxxxxxxxx <br /> 1 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) uJ. O q <br /> E <br /> # Tanks = _ 1986 1 1987 1988 1989 1990 1991 1992 1993 1994 1 1995 1996 <br /> F (multiply # by feefor <br /> A each year applicable) XXXX XXXX X%%X %XXX XXXX /''� I?D �� 1 70 ,�O $ <br /> C— <br /> 1 TANK PENALTY FEES ASSESSED XXXX XXXX XXXX Xxxx XXXX 00 /10 11 70 S /") <br /> L l <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, section 25287 <br /> T <br /> Y # Tanks x 256.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> �2t 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 <br /> CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimua/FACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review d Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours mininuWTANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) 5734.00 minimus S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 3 <br /> 1 <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE - 578.00/hr $ <br /> TOTAL DUE s /700 <br /> FOR OFFICE USE ONLY <br /> .::—_........._._...._......_.__._.__.....:::_._..____..._..._____: .._...._....__.___.____......._._.._._.__.: <br /> H SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED _ <br /> " S = <br />