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SAN JOAQUIN COONBLIC HEALTH SERVICES - ENVIRONMENTAL HEAL�VSION <br /> UNDER ND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME C'- i ,p-7 FACILITY CONTACT NAME <br /> T Trzv %r UVI �c�cLn <br /> E FACILITY ADDRESS SITE PHONE At with AREA CODE <br /> & l 0 f/O L 0 C 'f/!F - D i-8/ - -:?(J(' -' <br /> CITY STATE ZIP CODE # of TANKS <br /> P <br /> A ilk�, at SITE <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I <br /> rtvc1( 5--ZH-/6'�� K <br /> C MAILING ADDRESS l APPLICANT PHONE # WITH AREA CODE <br /> A / �. / C/416) <br /> N pp <br /> T CITY n^ STATE ZIP CODE TYPE of APPLICATION Cdd 11-, ruN <br /> - (Closure, Installat , etc.) <br /> __TDf L <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 8100.00 1986 1987 1988 1 1989 1990 <br /> A $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX S <br /> 1 <br /> V TANK FEE - 850.00/TANK (Prior to January 1,1991) f170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1 1996 <br /> F (multiply # by fee for - <br /> A each year applicable) g <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX f <br /> L <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x 856.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 878.00/hour (3 hours minimuNTANK) # TANK(s)_ X $234.00 = f <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum f <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 878.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum 8 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimm/TANK) # TANK(s) X $234.00 = f <br /> A <br /> I TANK RETROFIT REPAIR FEE = 878.00/hour (3 hours min./FACILITY) = $234.00 mini mm $ <br /> R <br /> PIPING REPAIR FEE = 878.00/hour (3 hours minimxVFACILITY) = $234.00 mini mm $ <br /> M TR FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 878.00/hr 8 <br /> I <br /> C CONSULTATION FEE = 878.00/hr yd `SAMPLING IN ECTION FEE _ $78.00/hr f <br /> TOTAL DUE S <br /> FOR OFC <br /> FICE US - <br /> ............ .................................................. ...................................................... .................... ....... .. <br /> wmxmw eee zow.z.ew.e..»z..e.m.x»x.u.ue.z.m.zew..e.xee�..x.»oae <br /> _ <br /> amu ea •••>••••» <br /> g.......!.«. '...... . Q/nEZ/x.. ..... !........ .....35 f — 3 yllslga <br /> ma�x�xmiromimoxexwxaxmxxwacwmrsaxaxaatca� ��srmaasx,ram�a� aav<a�mxx�m�mxm�,wx.a�mx,ax�aaxa�amxzm,»arxax�a�mwax <br /> EH 23 032 (REVISED 3-1-93) Pace 11 <br /> 1 <br />