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SAN JOAQUIN 0 PUBLIC HEALTH SERVICES - EWVIRO11MENTAL <br /> UNDERGROUND STORAGE TANK PROGRAM FEE U= <br /> SHEET <br /> FACILITY SITE NAME f} fi FACILITY CONTACT�AME <br /> Lifle-IDi;JflLi <br /> ' T SITE PHONE # with AREA CODE <br /> EI FACILITY ADDRESS -n ,, �^ 4 `-T) <br /> /U Aj� � 7 <br /> 1 & STATE ZIP CODE 9 of TANKS <br /> CITY at SITEA 04 <br /> ' <br /> P APPLICANT CONTA NAME <br /> P APPLICANT/BILLING NAME r ,� <br /> L J�/f iJ `i <br /> ' I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS ��r ��� <br /> A -�1 S�1 �A c.d ��C_ �� <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITYr� (Closure, Installation, etc.) ,elo()A <br /> f L' TOTAL <br /> 1986 1967 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 $ <br /> A <br /> C7000( %000( 5 <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) <br /> IV TANK FEE = $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks 1 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for S <br /> A each year applicable) <br /> C $ <br /> I TANK PENALTY FEES ASSESSED XXOO( X700( <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California N & S Cade, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 throw 1990 1991 through 1996 <br /> ' (Enter amount and year) S <br /> s/ °° <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK 1.0. #(s) 3 0 g <br /> L <br /> 0 CLOSURE FEE = $76.00/hour 0 hours minimun/TANK) # TANK(s)�_ X $234.00 <br /> S 1 oo�N <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E FTEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimun/FACILITY) = $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review& Construction Inspection ) TANK I.D. #(s) <br /> L <br /> A ' <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum 5 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minim.m/TANK) # TANK(s) X 3234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = S234.00 minimus $ <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S <br /> 1 M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE _ $78.00(hr 5 <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> tsass tF` ` <br /> �............... _._._.....,. .....�- .._.�.... s..... .._..,�__... ... .�_.. _� ._ ____._ ..................-- <br /> ""WM <br /> EH 23 032 (REVISED 3-1-93) Pace 11 <br />