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SAN JOAQUIN SY PUBLIC HEALTH SERVICES - ENVIRONMENTAL�TH DIVSION <br /> GROUND STORAGE TANK PROGRAM - FEE WORKSH <br /> FACT L � S]TE f�AME �/ C, �S�D f�(7 �� (AGILITY CTACT NAME A \ <br /> T <br /> l� KL�C , yl J T o TT6 /'P""/ <br /> E FACILjTy ADDRESS 671- <br /> SITE PHS E with AREA � <br /> & ' T <br /> CITY STATE 21P CODE # of TANKS n <br /> A � cjy9�_ 9� at SITE <br /> P v <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION T <br /> (Closure, InstaLLation, etc.) /j AGK <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A xxxx xxxx xxxx xxxx p p s j&0 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX xxxx XXXX XXXX V U S 1 oo <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) S170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = J_ 1986 1987 1988 1989 1 1990 1991 1992 1993 1994 1 1995 1 1996 <br /> F (multiply # by fee for <br /> A each year appL,cabLe) xxxx xxxx xxxx xxxx 166 /10 170 p 5 Q(� <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX xxxx XXXX XXXX $ <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See Ca Lifornia H & S Code, Section 25287 <br /> T <br /> Y # Tanks _ x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) t/ Bay �T �O $ .� <br /> 156 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ x $234.00 = 5 <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/FACILITY) 5234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 878.00/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 = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 878.00/hr S <br /> N1 <br /> 5 <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = S78.00/hr $ <br /> TOTAL DUE 5 <br /> FOR OFFICE USE ONLY ,.,,, <br /> ......................................................................................................_..............................._...................................__..........................................................................._........._................... <br /> :::::v::::::::::::::::::::::::::::::.::...::..._._.....::.........:.._......__...........:.........._Lc3._L._._.....:. <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RE El DATE RECEIVED <br /> VED CHECK #/CASH RECEIVED 8Y <br /> 5 <br /> Ml <br /> c i!!!!!!!!ME <br /> .......... <br /> EH 23 032 (REVISED 4-6-95) • • <br />