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SAN JOAQUIN COUNTY P HESERO <br /> ENVIRON,YIENT ALTH TVISI0NS <br /> UNDERGROUND STORAGE TAiNX PROGRAM .FEE W ORISSHEET <br /> FACILITY S E NAME F 1LITY C9XTACT. NAME <br /> S / <br /> I rCiv.Ql <br /> 7 SITE PHONE # with AREA CODE3S� <br /> E FACILITY ADDRESS �JJ <br /> X35 o �, o U <br /> A NATE Z C E # of TANKS <br /> CITY 11--�� L at SITE <br /> A TC iii ofl ' <br /> P APP ICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L 4 . 4h Cj e011&r <br /> I APPLICANT P ONE #-WITH AREA CORE <br /> MAIL NG ADDRESS II- � t^ Z <br /> G <br /> 8 CITYgtE Z P CODE TYPE of APPLICAllation, etc.) C-��5v+"- <br /> CTION <br /> STot{«oo t 52ra <br /> TOTAL <br /> A TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After- January 1, 1991) <br /> C <br /> T 4! Tanks = y_ �1986 1987 1198& 1989 1994 1941 11992 11993 11994 � 1995 1199b <br /> Y eachtyea� applicable)fee r XXX XXX <br /> X XXXX XXXX I XXXX I 13 <br /> E TANK PENALTY FEES ASSESSED I XXXX XXXX ! XXXX XXXX I XXXX I I S <br /> S <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> E # Tanks x 556.00 1986 through 1940 1941 through 1996 <br /> (Enter amount and year) p — I S <br /> CI PERMANENT CLOSURE Remova r Authorized Closure-in-Place) TANK I.D. »(s) -- <br /> LG.� <br /> 0,- FEE - S78.0C/hour (3 hours minimum/TANK) # TANK(S)__L_ X $234.00 = 5 Z)j <br /> S ` <br /> U <br /> TEMPORARY CENSURE (Plan Review 8 Inspections) I TANK I.D. �(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review S Construction Inspecticns)I TANK I.D. R(s) <br /> L <br /> Ag <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) - 5624.00 minimum <br /> R REPAIR FEE (Workpiarn .Review 8 Construction Inspections) TANK I.D. 4(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = 5 <br /> A S <br /> I TANK RETROFIT REPAIR FEE = S78,00/hour (3 hours min./FACILITY) = S234.00 minimum <br /> R 5 <br /> PIPING RE°AIR FEE = 578.00/hour (3 hours minimurrslFACILI7Y) = 5234.00 minimum <br /> H TRANSFER FEE = $20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I 5 <br /> I <br /> S g <br /> CONSULTATION <br /> C FEE = S78.00/hr I SAMPLING INSPECTION FEE = 578.04/hr <br /> 7fl7AL DUE <br /> a5 � O <br /> GE..USE....QNiY..... _ T...._.—..._—:._-:.—:::-:-,.. __---..._._- .___:::_•:: ::w :_:-__mss:- ;: _�..;....-:_:--=_::__:_•-- �T_ <br /> _.....-.....-- — ...._...._.... ...:.:..::.a - <br /> -SWEEP5_TM COMPUTER LOC CODE —621-'C- <br /> E. <br /> 62 Ci AMOUN RECt[VED CHECK' �JCASH T RECEIVED BY I DA#E RECEIVE <br /> I - <br /> tF n <br /> i <br /> EH 23 046 (Revised 7110/96) Page 11 <br />