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SAN J0AQUIN Cqj t PUBLIC HEALTH SERVICES - ENVIR0WNTAL H&H DIVSION <br /> (N4pbRUp STORAGE TANK PROGRAM - FEE WORKSHEEMW <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T �aF� <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & <br /> 2. / C . DAA ST <br /> A CITY D�_ STATE ZIP CODE # of TANKS <br /> �1 �/ ;� at SITE <br /> P U � <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> C MAILING ADDRESS APPLICANT, PHONE # WITH AREA CODE <br /> T CITY r r ST TE ZIP CODE TYPE of APPLICATION <br /> -tel" (7 3�pLj (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> AXxxx xxxx /Oo too /0U f 30CJ <br /> C <br /> T FACILITY PENALTY FEES ASSE ED (I A Le xxxx xxxx too IOL) S D D <br /> I <br /> V TANK FEE = 550.00/TANK rio J ry 1 1) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = ( _ 1986 1 1987 1 1988 1989 1990 199f 1993 1994 1995 1996 <br /> F (multiply # by fee for �. <br /> A each year applicable) xxxx xxxx 5� Sd �j f� / �c ! 70 S �D <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx U �J SO ! 7 1 7Q S [� <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks I x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> Pd f <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L n <br /> 0 CLOSURE FEE = 578.00/hour (3 hours mininAVTANK) # TANK(s)�_ x 5234.00 - / $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X 5234.00 - f <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workp(an Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ x $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) - $234.00 minimum f <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr f <br /> I <br /> S <br /> Cl CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr $ <br /> TOTAL DIE f <br /> FOR OFFICE USE ONLY <br /> SWEEPS At COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK $/CASH RECEIVED BY DATE RECEIVED <br /> s'i f <br /> ::._...........___............:.. _.._. .._. ..._._.___ .__. .. ._.__......___.. .�_._ er-.- :..-:�:�...______._�:- ..__ _..._.__....._......'. <br /> .........._..__.....................__._......................._:::_:....._.....____.___.__.._._....._.__........._...................._....____..................__._....__.___.__..._._.._.........._.._.........._....._.._._..._...._.._...._.�- ._..- _—*.EE <br /> EH 23 032 (REVISED 6-21-93) Page 11 <br />