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SAN JOAQUIp PUBLIC HEALTH SERVICES- ENVIRONMENTAL MTN DIVISION <br /> UNLe GROUND STORAGE TANK PROGRAM - FEE UCIRKSHEETIW <br /> 5 FACILITY SITE NAME ? FACILITY CONTACT NAME <br /> T SITE PHONE # with AREA CODE <br /> E FACILITY ADDRESS <br /> 30 i i-uM A <br /> L STATE ZIP CODE # of TANKS - <br /> A CITY C4 �` at SITE <br /> P / 7 <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N D . .. <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 xxxx xxxx xxxx xxxx xxxx S xxxxxxXxxxXxx <br /> A <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> xxxx xxxx xxxx xxxx xxxx f xxxxxxxxxxxxx <br /> I 5170/TANK (After January 1, 1991) <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) q'' <br /> E <br /> 4 Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) xxxx xxxx xxxx xxxx xxxx )'7 e. i7o (7p 570 170 $ 107,0 !�o <br /> C <br /> I TANK PENALTY FEES ASSESSED Xxxx xxxx xxxx x%%% %%X% 1'1'0 + AID ��� )�� f 1 07,C) l D <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H d S Code, Section 25287 <br /> T 1991 through 1996 <br /> T # Tanks I x $56.00 1988 through 1990 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L # TANK(s)__ X 5234.00 = S <br /> 0 CLOSURE FEE 578.00/hour (3 hours minimus/TANK) <br /> STANK I.D. #(5) <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) <br /> Rum f <br /> E TEMPORARY CLOSURE FEE _ %78.00/hour (3 hours minimum/FACILITY) $234.00 minim <br /> P INSTALLATION PLAN CHECK (Plan Review d Construction Inspections) TANK I.D. #(s) <br /> L <br /> A $624.00 minimum f <br /> N PLAN CHECK FEE = 578.00/hour (B hours minimus/FACILITY) <br /> R REPAIR FEE (Workplan Review d Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 978.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 S <br /> A = 5234.00 mi ninum S <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br /> R = $234.00 minimum S <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr f <br /> I <br /> S = 578.00/hr % <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY n .mm eer_mmmnmmtmmmmm�sr.:!xsx !s!m!mm+!.-M—mm.esr!mmmm�mm!!c!!m:nn!mmpm!m!nxsmmnmmn.. <br /> mmwrx^!^m!mrr!e^.tnm!.�m!nnm,.z:!mm! am see RHO.. <br /> xnmmm�nxmx,,ams!!!xnnnxrmxmme!! .m,'.+.^mmmmmxn.xmrdmm�mimaawi!!rievarwritmusnmx!wmmrmrxummmn,w mmnmm�munummmsxxmmnm;m!nmunmiiii;nmm;m!mxurmm!Goa <br /> umnmxmnwnn!unnnnmm!.mem!ma <br /> SWEEPS It COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> m <br /> 91 t <br /> !xmmmsx i <br /> „,::�•:.:..::...::::.:-::;. ,twe—== ex!!xo.,m!x!r!mmm:!m1:!s.:^.: +.^uxm!!ntmnrx_m!mev!.^.!!rm:�+xm!nrnmmmm!.. ._twms!!xsssmm!!m:.mmmwnnv!!t!mmmxn!!m!m.�s!s,<!!!mn!!wrmm!r:.m!m!mm!srmem <br /> nix!:,v........!.....aa............... .m. <br /> nm!:u!rnx!xm!.=.m!!nmm�nm:aui!i!xxxmx!!nnsxfi:�!mtmmra!x!mmatmtn,;mm�imx!aaannnmmrudmxiaim�mmwwmmmriuuawmnm®trm®nnnumammuaimmmxmmxrmmnmmw!mmtxwnmmnu!!nmtwmmwmmmwnxtnwnnmm <br />