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SNI JOAQUIN CO" PUBLIC HEALTH SERVICES - ENVIRON ENTALH DION <br /> L•"'Te•.T'"NO STORAGE TANK PROGRM - FEE WORKSHEEEWIVS <br /> S FACILITY SITE NAME FACILITY ppCONNTACT NAME <br /> T n am <br /> E FACILITY ADDRESS SITE PHONE Awith AREA CODE <br /> 1031 r= Lcw5e- <br /> CITY <br /> pq-A a/� Ian STATE ZIV CODE of TANKS <br /> P �LYn7T L:-IV tAi�l'/). O4./K3 at SITE I <br /> P APPLICANT/QILLINNGaNAME APPLICANT CONTACT NAME <br /> L cVl amb <br /> 1Samc <br /> CMAI NG DORESS APPLICANT PHONE y WITH AREA CODE <br /> N �D �� IG 3 cc c`JJJI/•MuY1L <br /> T CITY E S ZI C �,/� TYPE of APPLICATION <br /> G�Le� � �1// (Closure, Installation, etc.) CJ <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to Jarwary 1, 1991) 5100.00 1986 1987 1988 1989 1990 <br /> A <br /> G xxxx xxxx 5 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx 5 <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> I Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply A by fee for <br /> C each year applicable) xxxx xxxx 5 <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx 5 <br /> L <br /> 1 STATE SURCHARGE 556.00 each TANK <br /> T (Due every 5 years) See California H 3 S Code, Section 25287 <br /> T M Tanks x 556.00 1988 through NPI) 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. R(a) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours mininuNTANK) / TANK(s) x 5234.00 <br /> S eCGJ7 <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) <br /> R TANK I.D. M(s) <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimum/TANK) M TANK(s)_ x $234.00 = 5 <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. k(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) 5624.00 minimum 5 <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minirmm/TANK) N TANK(s) x 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum 5 <br /> M TRANSFER FEE <br /> 1 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> 5- <br /> -C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr 5 <br /> TOTAL NJE s !J2 Qd <br /> FCR OFFICE USE ONLY G[✓ <br /> ..........._.................. mmmtx:::'''"`"`'saga==:e :;=:::_::�::::::::::�:,-::,:::::::--.:,::_-_:::-._......._..___..... ...._. ..._...._. ._.........._._..._._..:..._....._.,...._.......................:--_ <br /> ;_ SWEEPS N I COMPUTER N I LOC CODE I DIST CODE I AMOUNT RECEIVED I CNECK�N/CASH I TRECEIVED ABT s I} DATE RECEIVED �T" <br /> :s 5 <br /> EH 23 032 (REVISED 6-21-93) Page 11 <br />