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I <br /> SAN JOAQUIN COLI HALIC HEALTH SERVICES - ENVIRONMENTAL HEAL' 1VSI <br /> UNDE*9(bURD STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE MIRE 9 FA ILITY, CONTACT MAN <br /> Iso� 0. (�W Q Ctk) C <br /> T <br /> E FACILITY ADD ESS ) ll SITE PHONE If with AREA CODE <br /> t 3 / n 0 11-c .1O 1)L <br /> CITY STA/iLE ZIP CODE N of TANKS <br /> A _ ® C�7 at SITE D <br /> D <br /> P ADPL M Tj ILLING NAME - / APPLI�T CONTACT NAME <br /> , <br /> e n c� �.JOIC.k- elle n <br /> C MAILING ADDRESS // I APPLICANT PHONE t WITH AREA CODE <br /> i CITY STATE 21 E TYPE of APPLICATION <br /> • Q � � (Closure, Installatfon, etc.) ( jOS"'n <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January t, 1991) • 2100.00 <br /> A f <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXIOf S <br /> 1 <br /> V TANK FEE + 250.00/TANK (Prior to JaM44y 1,1991) 2170/TANK (After January 1, 1991) <br /> E <br /> R Tanks = 1986 -1987 1988 1989 1990 1991 1992 1 1994 1995 1996 <br /> F (multiply fee for <br /> A each year applicable) 7 S <br /> C <br /> I TANK PENALTY FEES ASSE 9"D X%XX %X%X ! <br /> L <br /> I STATE SURCHARGE 256.00 each TANK (Due every 5 years) See California N 6 S Code, Section 25287 <br /> T <br /> Y S Tanks X $56.00 1986 through 1990 1991 through 1996 <br /> (Enter unt end year) <br /> t <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Piece) TANK I.D. 1(s) U IL t <br /> 0 CLOSURE FEE + 278.00/hour (3 hours mfnfnWTANK) N TANK(s)_ X 5234.00 • 2�3 ��"'` <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 6 inspections) TANK I.D. f(a) <br /> R <br /> E TEMPORARY CLOSURE FEE + 278.00/hour (3 hours minfmm/FACILITY) $234.00 minimus ! <br /> D INSTALLATION PLAN CHEC ,(Plan Review f Construction Impect (s) <br /> L ovieg��py�� <br /> A �7 X624100 <br /> N PLAN CHEC E = 278.00/hour (8 hours minirmm/FACILITY) Noy <br /> + minfmun f <br /> R REPAIR FEE (Workplan Revleft Construction lnspeWl&4LICHj L <br /> P TANK LINING REPAt .&E + S78.00/hour (3 hours mfnimm/TANK) NIEh0"jjW_�' X 2234.00 • 2 <br /> A <br /> I TANK RETRO FI EPAIR FEE + 278.00/hour (3 hours mfn./FACILITY) + 2234.00 minimus $ <br /> R <br /> PIPING PAIR FEE + 178.00/hour (3 hours minfnWFACILITY) + 2234.00 minimm f <br /> HEIRANIFER 2 :1>0 UNAUTHORIZED RELEASE EVALUATION • t78.OD/hr ! <br /> 1CFEE • 278.00/hr SAMPLING INSPECTION FEE + 278.00/hr f <br /> TOTAL DUE f '✓ <br /> FOR OFFICE USE ONLY <br /> »......_._g;_...........«.....»_._..._.._..__._..._.._»»»..».»..._.._..._..._.._.------»»».... .._.-.....__.._.___.._...._..«__»_...._...._._.___....»....._._.__.._..._._ <br /> r= �(a� a (se�� "-uLvFr====irFrrni�r`= <br /> X ! <br /> M' Glkl maF of r�W,M, lwi }I fIaM s"WmFinam"ars"+irfw flys ManlM a�ItY MIM eiY N If�WAMtYN llmaf�M MIIMIfaY <br /> EN 23 032 (REVISED 3.1-931 Pace 11 <br />