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SAN JOAQUIN CO(A,_. PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEA DIVSION <br /> UNDERGROLM STORAGE TANK PROGRAM - FEE WORKSMEET <br /> i - <br /> T ----.. <br /> E FACILITY ADDRESS YTE PHONE # with AREA CODE <br /> & <br /> /ZZ ,e—. GUD� /9��, Z�+) 69-- b <br /> CITY STATE ZIP CODE # of TANKS <br /> A GUP�' �� d at SITE 3 <br /> P <br /> APPLi CANI{111LLING RgqAN��T�� k"ILIMI MNIM MANE <br /> C NAILING AI APPLICANT PHONE # WITH AREA CODE <br /> A c�'Yw4-h yon <br /> " /AGE B/GG <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> U 6• T- FEES f<--x— TOTAL <br /> 216 /�ieESE^t-r <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FA EC__ 991) _ $100.00 — <br /> c /ba /oo /a7 icb 2x> S $o 0 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx /pp /Ob /00 $ 30 0 <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to Jamary 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) /Xj 1150 iso /go 160 5/0 5/0 5o SZ 2-So <br /> C <br /> LTANK PENALTY FEES ASSESSED xxxx xxxx /e;j;> 110 /10 % /q70 <br /> I STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount end year) <br /> /6gI 16 S 336 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # 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/TANK) # TANK(s) X $234.00 = S <br /> N[PLAN <br /> INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> CHECK FEE _ $78.00/hour (8 hours mini mim/FACILITY) _ $624.00 minimum f <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) K $234.00 f <br /> A <br /> I TANK RETROFIT REPAIR FEE _ !78.00/hour (3 hours min./FACILITY) _ $234.00 minimum f <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION - 578.00/hr S <br /> I <br /> $ <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = 578.00/hr f <br /> TOTAL DUE f <br /> FOR OFFICE USE ONLY <br /> ...:-r.+:.ammmm!xmmmrsa:emx!!;;!mm!!!em!mmm.=.!rtms<cxmrn!mmarmxn!a.�a:�..mmmmm!!-nmmm:mx!!!!enm::. rn: - .. . . <br /> -.._..........:..... ............._ . ._. ..... ........ ....... .. .... .. . ... .-! ..::-,,!:-. .:: <br /> EIVE:r:nn::::..r.r.r..!..:..:::.:m:.:axc:.,,:,:a.n:::.:::r:u!r.:,,, <br /> _ SWEEPS # COMPUTER # LOC CODE DIST CODE ANOUN7 RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED d <br /> :-: Xmmmmmmm!namm!mm!::. =!:m!mµcn!a!nx,=: . <br /> !,-,: ..._..,... : .:-�::_:-:�- ,:.:.::.:�..T.:,__ ...:......... .... . . .._ .......... _..... ............. <br /> ......_._-__-. ..d.P.LY:-vi!'�v::nA.Wximl�xd_i.:.._.:�.:x!h_.ux:..:9:'1.._�a:v. Iu:LF.dn!:alSr!:Lh�i,e!:!!!::uL',A:,n::!3!:T1.::!: G::�:_N::::3i:i!3 <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />