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SAN JOAQUIN�TT 7UBLIC ID:IU.TH SERVICES - ENVIRONMENTAL'#H DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKS <br /> SI FACILITY SITE NAME_ FACILITY CONTACT NAME <br /> n r. <br /> 1 -L, /?., I 1 V l J <br /> E FACILITY ADDRESS SITE PHONE 7 with AREA COOE <br /> z _ <br /> CITY / f��� STATE ZIP COOE k of TANKS <br /> A c7/ _.4' ,; as SITE �) <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C NAILING ADDRESS APPLICANT PHONE H WITH AREA CODE <br /> A <br /> T CITY STATE ZIP CCOE I TYPE of APPLICATION •%{1��� <br /> (Closure, Installation, etc.) <br /> 1986 1987 1988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 2100.00 -� <br /> A )� � ['0 <br /> C , <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXAO( I'XxO(• /io r �) �iV`��� S -� l 1 <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to :an ary 1,1991) 5170/TANK (After January 1, 1991) <br /> E S Tanks = 1 1986 1987 11988 1989 11990 11991 11992 1993 1994 11995 1996 <br /> F (Multiply x by fee for <br /> A each year applicable) )0= XXXX t *Sjif, <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX KOO, ��(,� ' �(� <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (7ue every 5 years) See California H b S Code, Section 25287 <br /> T <br /> T Y Tanks x 556.00 1588 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S C S l l ,�- <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK 1.0. x(s) <br /> L <br /> OI CLOSURE FEE 578,00/hour (3 hours mini—/TANK) N TANK(s)_ X 2234,00 2 <br /> S <br /> Ul TEMPORARY CLOSURE (Plan Review 3 Inspections) I TANK [.D. Y(s) <br /> R <br /> E TEMPORARY CLOSURE fEE = 578.00/hour (3 ;loon minimum/FACILITY) 5234,00 mininum S <br /> P INS7AlUTION PUN CHECK (Alan Review i Construction Inspections) TANK 1.0. Y($) <br /> L <br /> A <br /> Al PUN CHECK FEE = 278.00/hour (8 hours zinim zVFACILITY) = 5624.0G minimum S <br /> R REPAIR FEE (Workplan Review 3 Conssructfon Inspections) I TANK I.D. !(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.001hour CS hours minimum/TANK) 3 TANKCS) _ X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE - 278.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/how (3 hours minimum/FACILITY) = 5234,00 minimAm S <br /> i <br /> N TRANSFER FEE = 520.00 WLAUTHCRIZED RELEASE EVALUATION - 378.00/hr I I S <br /> SlI <br /> r <br /> Cj CONSULTATION 1F��EE�� - S78.O0/hr �gSA�wLIINr INSPECTION FEE = 578.001hr I S •- <br /> ^^ �C.v'rn- II�j (� TOTAL DUE S v c� <br /> FOR OFFICE E USE ONLY 14 p 11 fi-yf c� a. - s - 93 Ili ` / "3_" j dUA_L:EE — <br /> SWEEPS $ COMPUTER S LOC MOE DIS CODEI AMOUNT RECEIVED CHECK .-/CASH RECEIVED dY I DATE RECE--INFO i <br /> 5 <br /> EH Z3 032 (REVISED 10-28-93) Page 11 <br />