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--_ ------- -- --HEAL <br /> - -- SAN JOAOUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSIUN <br /> WND STORAGE TANK PROGRAM - FEE WRKSH <br /> FACILITY C T NAME <br /> S FACILITY SITE NAME _ <br /> I <br /> T SITE PHONE # with AREA CODE <br /> E FACILITY AODR SS T <br /> & STATE ZIP CODE # of TANKS <br /> CITY at SITE <br /> A <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/SILLIMb NAME <br /> L <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N S7ATE ZIP CODE TYPE of APPLICATION <br /> T CITY (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 5 <br /> XXXX XXXX XXXX %X%% <br /> A <br /> CXXXX XXXX XXXX XXXX 5 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I 5170/TANK (After January 1, 1991) _ <br /> V TANK FEE = 550.00/TANK (Prior to January 1,199 ) <br /> E <br /> # Tanks <br /> _ _� 198E1987 1988 1989 1990 1991 1992 1993 1994 199` 1996 y;F (multiply # by fee for A each year applicable) %XX %%XX XXXX <br /> E <br /> CI TANK PENALTY FEES ASSESSEDXXXXXXX XXXX <br /> L <br /> Code, Section 25287 <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S <br /> T1988 through 1990 1991 through 1996 / �, c cf� <br /> Y # Tanks x 556.00 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) <br /> TANK I.D. #(s) <br /> __ X 5234.00 8 <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /> S TANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R 8 <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L 8 <br /> A = 5624.00 minimum <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br /> TANK I.D. #(s) <br /> R REPAIR FEE (Workplan Review & Construction Inspections) E <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) % 8234.0 = <br /> A = 8234.00 minimum S <br /> I TANK RETROFIT REPAIR FEE = 878.00/hour (3 hours min./FACILITY) 8 <br /> R = $234-00 minimum <br /> PIPING REPAIR FEE = 878.00/hour (3 hours minimm/FACILITY) <br /> IMTREANSFER E = 820.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br /> = 878.00/hr EN FEE = 578.00/hr SAMPLING INSPECTION FEE 30 oe <br /> TOTAL DUE E <br /> ..___..__...._..._....-.—........:.::.::::::::.:: <br /> USE ONLY ..:,_--:::.,—,-==R:,-r:'^e-:T;-:'-°.. -:-_ .__.._...___..__...:.....:�, EI FOR OFFICE U .-:,--'T"' ::.,{„-. .._.:::.:_�:...__ ...., <br /> ------ --::::�t tt§!tr'.'�E a=:::::_r:::: _...__.....:.:.-:�::.-.....__.. __....-__.._::,:=:tet;':•CE:�:. ._-:Y RECEIVED <br /> !::::::-:::::: . ...._......._....._._._.::....__.....—_:: :::_:...:::_:::!::_!:_:::_ mt✓�; !�ED :_;.-__.._._._._.__. RECEIVED BY DATE RECE a <br /> SWEEPS # COMPUTER # LOC CODE GIST CODE AMWNT RECEIVED CHECK : <br /> s 8 a <br /> :. ..__.....:.:—.:-v:::::::::..........._- r-_:r .._.c:�.::_'__........—_.._ _;a!i:a!!!J_._::_c:i::�n�!::_-+n^ <br /> 41) <br /> � Iall <br />