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C i o5are S4vSION UDD5�' <br /> SAN JOAQUIN COUALIC HEALTH SERVICES - ENVIRONMENTAL HFJ1L 17 :Jl 3 5 <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET '/ ✓ / l <br /> FACILITY CONTACT NAME , <br /> FACILITY SITE NAME aA og ��5u <br /> 1 � L <br /> T SITE PHONE # with AREA CODE <br /> E FACILITY ADDRESS 2 2 / <br /> Z s m Af <br /> & STATE ZIP CODE # of TANKS I <br /> A <br /> CITY ko, f <br /> at SITE 1/ <br /> P APggLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME �/ �•� ILON <br /> Z <br /> C MAILING ADDRESS/,/' APPLICANT PHONE 7-4/"# WITH AREA CODE <br /> A 2/ �h S f Zo 5 6.S-3 <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITY ��06(o CjI 5--/ (Closure, Installation, etc.) <br /> �f TOTAL <br /> 1986 M19871,91019 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 00 T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX <br /> uary 1,1991) <br /> V TANK FEE = 550.00/TANK (Prior to Jan <br /> 5170/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 S �.� S 3ZrJ.00 79aA <br /> A each year applicable) l '^ �q <br /> 1 TANK PENALTY FEES ASSESSED XXXX XXXX S S� �Q �� 2-0 r S �w �OaI,O <br /> L �yv <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & s Code, Section 25287 <br /> T 1986 through 1990 1991 through 1996 <br /> Y # Tanks x 556.00 <br /> (Enter amount and year) Ol7 /- Q� S Z- 9yo/ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> Lum # TANK(s) X $234.00 = 5 23 i0Q <br /> O CLOSURE FEE = 578.00/hour (3 hours minim /TANK) <br /> STANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimus/TANK) # TANK(s)_ X 5234.00 = <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A $624.00 minimus S <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimus/FACILITY) <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E S <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) ,_ X 5234.00 = <br /> A S <br /> f TANK RETROFIT IT REPAIR FEE = E78.00/hour (3 hours min./FACILITY) = 5234.00 min i mm <br /> R = $234.00 minimus f <br /> PIPING REPAIR FEE = 978.00/hour (3 hours minimm/FACILITY) <br /> M TRANSFER FEE = E20.00 UNAUTHORIZED RELEASE EVALUATION = 978.00/hr <br /> Q�e7 S = 578.00/hr C CONSULTATION FEE = E78.00/hr SAMPLING INSPECTION FEETOTAL OU: <br /> FOROFFICE USE ONLY _.._ .._:-•—:.- :=:,r.......:'":.�=:::_•::::_-::........:... ....:...s:..::.....:.._....:..:.....:-._._...................!!r; ...:.... <br /> nh, _.............,.._..::,...........::::::..................:..............�.al.r...:!..;.::- ....._. ................;._ ..�.—....:::::::::: :::!e::_!:..:_ auuA;:,: a:ra...... ::::::,:::::::::::m:! w iii9 <br /> ............._.....___........._.......... i!ieiF!e!!e;; Jul!cul:c:::3!i!!;uY::!ii�nly!:V::nvn:::.:.�.:.11lu�_.__: <br /> SWEEPS COMPUTER COMPUTER # �LOC CODE DIST CODE AMWNT RECEIVED CHECK /CASH REC VED BY DATE RECEIVED �l <br /> 3 <br /> -::�:�:3z!rt�Nt!'���=!!a-.:�::_:-_::::::_� :stir;;;::;i::::::.::_y!a::ic!v_ ::: <br /> EH 23 032 (REVISED 11-1-92) * -_ Page 11 <br />