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SAN JOAQUIN COLO PUBLIC HEALTH SERVICES - ENVIRONMENTAL H* DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE (IORKSHEET <br /> FACILITY CONTACT NAME <br /> S FACE ITY SITE NAME <br /> 1 <br /> 7 SITE PHONE # with AREA CODE <br /> E !AGILITY ADDRESS ; <br /> R r_I) lfiVlJ\ _ .S^TAATE Z P CODE # of TANKS / <br /> `J•�e at SITE <br /> CI Y <br /> A <br /> v APPLICANT CONTACT NAME <br /> P AP CANT/BILLING NAME <br /> L <br /> APPLICANT PHONE # WITH AREA COD <br /> 1 <br /> C MAI NG ADDRESS <br /> A O TYPE of APPLICATION <br /> H STATE 21P CODE <br /> T CITY /l�-YidT. 6> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 , %Xxx xxxx XXXX XXXX xxxx E xxxxxxxxxxxxx <br /> A <br /> XXXX XXXX XXXX %%X% XXXX E %%X%KK%%X%%% <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) f170/TANK (After January 11 1991) yj <br /> 1 Prior to January 1,1991) <br /> V TANK FEE = 550.00/TANK ( <br /> E 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> # Tanks = 1 _ �1 J� ,,µA� V11 E <br /> F (mol[iply # by fee for gXX% XXXX %XXX X%%X X%%X /Q /�](� "/V f <br /> A each year applicable) <br /> C <br /> 1 TANK PENALTY FEES ASSESSED %%%% <br /> L <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Lode, Section 252 <br /> 87 <br /> T 1988 through 1990 1991 through 1996 <br /> Y # Tanks x 556.00 E F <br /> (Enter amount end year) <br /> TANK I.D. #(s) - a <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) X 5234.00 = $ <br /> L N TANK(s) <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /> STANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) 5 <br /> R <br /> E TEMPORARY CLOSURE FEE 578.00/hour (3 hours mi nimun/FACILITY) 5234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review A Construction Inspections) TANK I.D. #(s) <br /> L $ <br /> A = <br /> N PLAN CHECK FEE = 570.00/hour (8 hours minimus/FACILITY) 5624.00 minimum <br /> LANK I.D. #(s) <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) _ <br /> E q TANK(s) % 5234.00 = <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) 5 <br /> A = $234.00 minimum <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (1 hours min./FACILITY) 5 <br /> p = 5234.00 minimum <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION <br /> = 578.00/hr 5 <br /> I 5 <br /> S 578.00/hr <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE TOTAL DUE 5 <br /> : !.......lei!li!li!ii!I!viii!i!illliilll!1!Ililli!Iil!!01I!!iell!III!°"!r!!!!I^!!°i�iii iiiiii0iiliiliiiiiiiiniiii iui iimiiiiiriii ria iinm°iiiin°l�I <br /> FOR OFFICE USE ONLY r nnnnnnn!nnnnnenl!nn!!I1!nennoel!!num!e!nnlll!!nenenn!nI!Iniu!n!I!llclnl!nlm!m.m DATE RECEIVED I <br /> enmml;en!!!m:ele!nnemnun.nannL::lu!e.nm n <br /> �IIIIeIilI111iI:e1e1!IIp11111!:iiee en,!Irlll:n!iln!e;!!;ei,Incur!I;Irliillrllrmllllllllllller llllllLAlllliiellllllllenepee umllllllllellnlllrmm�ii4l!erliilnlllrnn mlmrnnlmrll!enllldlinimirlilllr:i!nl0rrmllm!mrinlllr,in <br /> SNEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY <br /> 111!1111!i!ii!I!II............!......... i!illili!!!Iiiillliii!11!!!!I!!i!!I11!eii!Illlel II!Ieeal!III�� <br /> m.... .Ili!!!I!II!!n!nrnn!!1!!nllnl...!...I.niiiriiaiiiriiii{iiiiiiiriiiiiiiiniinri� en!Inmm�nnnnlnnnnmmnnnmenunnmm�emm�mm�mnnnm!�mm�numm <br /> m <br /> nlrn.umnnn;r'nl:e:ll aennl nl r r.e:mnnnn:•nn!nnemdunlllemennenlelrlll;�r!1°!r,;ne!nen:e,lll er"rnnan!nennmllnmm!mumm � - <br /> t <br />