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SAN JOAOUIN COUN�LIC HEALTH SERVICES - ENVIROu1ENTAL HEAaVSION <br /> IAIOER /J(STORAGE TANK PROGR - FEE UORKSHEET <br /> 5 FACILITY SITE NAME �� / �GfJS FACILITY ACNAME <br /> r <br /> FACILITY ADAR�SS SITE PHONE N w1tt'h AREA CODES <br /> 33Y <br /> CITY STATE ZIP CODE� N of TANKS <br /> A 2µ.i at SITE <br /> P <br /> L APPLICANT IOhI SGW/!-lpi �(N"7 f C. O. �OG NAME APPLICANT <br /> FCON N��, <br /> 1 7/F F�-iG <br /> C MA INC AD E55 c APPLICANT PHONE N WITH AREA CODE <br /> A u,.0 cJ'O <br /> N n. <br /> T CITY <br /> STA E ZIP CODE TYPE of APPLICATION <br /> �'1 N �' 9SZp/ (Closure, lns[alLaTIM <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A X%xx Xxxx .G� t <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) Xxxx xx%X t <br /> I <br /> V TANK FEE = LSO.00/TANK (Prior to January 1,1991) 1170/TANK (After January 1, 1991) 2) <br /> E / <br /> N Tanks ` 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply A by fee for - --- <br /> A each year applicable) xx%K x%%% r;-., .ty ?y.lt.. ^.�fLl y/-- /y, S <br /> G i56t- <br /> I TANK PENALTY FEES ASSESSED x%xx %XxX <br /> L f 56a <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 6 S Code, Section 25287 <br /> T — <br /> Y N Tanks_ x %56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> I 9 l�tZ <br /> g81 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. N(9) �^I <br /> N <br /> 0 CLOSURE FEE = %78.00/hour (3 hours miniaRm/TANK) N TANK(s)-/L X %234.00 t pl Or' <br /> S <br /> U TEMPORARY CLOSURE (Plan Review d Inspectl ons) TANK I.D. N(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ [78.00/hour (3 hours minimm/TANK) N TANK(s) X %234.00 = t <br /> P INSTALLATION PLAN CHECK (Plan Review d Construction Inspections) TANK I.D. N(s) <br /> L <br /> A <br /> N PLAN CHECK FEE _ 178.00/hour (8 hours mini mum/FACILITY) _ %624.00 minimum t <br /> R REPAIR FEE (Workplan Review t Construction Inspections) TANK I.D. N(s) <br /> E <br /> P TANK LINING REPAIR FEE _ %78.00/hour (3 hours minimum/TANK) N TARK(s) X $234.00 = t <br /> A <br /> 1 TANK RETROFIT REPAIR FEE _ [78.00/hour (3 hours min./FACILITY) - %234.00 minimum t , <br /> R <br /> PIPING REPAIR FEE • [78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum % <br /> N TRANSFER FEE • %20.00 UNAUTHORIZED RELEASE EVALUATION - %78.00/hr t <br /> t <br /> S <br /> C CONSULTATION FEE _ 978.00/hr SAMPLING INSPECTION FEE 578.00/hr t <br /> TOTAL DUE % <br /> OR OFFICE USE ONLYI <br /> , !!;;���,���!!!,!�!!�;!�. <br /> in <br /> !;; 1111111 1M. <br /> SWEEPS N COMPUTER N LOC CODE DIST CODE AMOUNT RECEIVED CIIECK N/CASH RECEIVED BY DATE RECEIVED <br /> :u <br /> .•.. .�:,::a......,:,:n : I : . ILLL.1...1.1.111. L11..1.1JIILLIL..11.....ILIIL.ILL..L.11111.%ILL.....IL.IL.t.l..l...a....:.!..........._a!...n.l.........n.ln.c9!lnnnclm: u Intl ::: ,: ,:I , ,,:n Ills:u,lo „ I:n�l� <br /> ::�:.;:L.�!.......1.......a...L!..n...nnuula..nn.nl.mnunn.l.Lamn..;.l.lamrn.(.... . .. .. . .. . .. . ..... . .. .. .. . ..... ..... .. .. . . :n;nn!n..u.l.....ln.l.l.:Inn.Lanl...Im.nuaa..a..l..nJ...l.l..na.11.a..l.,l <br /> c :: : :n n 1 I .;,nilllll;l9,l I: 1:1111!IUIIIIIILI211:!I!IlLlala!1:11!II'I!I!I II!II 14:1'!4!1111 ullnll:11 F II.I!Iln.a:^II:IIII!PI�I!!IIII!11111111 IIII I :I r :I� I�I : : � .,r n:m I:: II�.r. I :II .. <br /> 'Ii�iSiiFi�!iii::!ii'isii!!iiiiii!ii6i!..IIIILIF!L,OIIR!i!IIIIJIII!IIILIIILL.ILII..livll.11la:. � .III III I I : t LI I - I .. III. Ilmllll.l!.LLIIIIILLLIIIIILLLILIILIIIIIIIIIL.IL:L.....ILLLIIIIIL.L..Il.11.l..11n� <br /> EH 23 032 (REVISED 6-21-93) Page 11 <br />