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SAN JOAQUIN CCUP" PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEA'— DIVSION <br /> UNDI`,3-30 STORAGE TANK PROGRAM - FEE WORKSHEET -A/ <br /> ffA - <br /> NAME FACILITY CONTACT NAME <br /> ITE PHONE x with AREA CODE <br /> w n --�— <br /> C �_ C.c�Q� �o 3 Co S <br /> TATE P C ! � K of TANKS <br /> k J a _ i �- 6, at SITE <br /> APPLICANT CONTACT NAME <br /> P APPLICANT LING NAME Tr C <br /> L <br /> 1 <br /> AMAIUN ADDRESS l APPLICANT PHONE # 41TN AREA CODE <br /> M <br /> T CITY •�, C // / 1 - STATE P E TYPE of APPLICATION <br /> n e� Y V (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) - $100.00 <br /> A xxx)( XXKX P" koer <br /> f J 9� <br /> c <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX bj loe f �cjOv <br /> I <br /> Y TANK FEE • 550.00/TANK (Prior to January 1,1991) 5170/TANK (After JerxRary 11 1991) <br /> E <br /> 1 Tanks • — 1986 1987 1988 1989 . 1990 1991 199 199 1994 1995 1996 <br /> F (multiply 7-67-fee for / / V f ly'L�R q9� <br /> A each year applicable) xxxx )000( I <br /> C <br /> 1 TANK PENALTY FEES ASSESSED XXXX xxxX /)o /t <br /> L <br /> 1 STATE SURCHARGE • S56.00 each TANK (Due every5 years) See California H a S Code, Section 25297 <br /> T <br /> T it Tanks-2: X (56.00 1988 through 19901991 through 1996 <br /> (Enter amount and year) <br /> - )- Eiii <br /> 9 <br /> C PERMANENT CLOSURE (Removal or Authorised Closure-in-Place) TANK I.D. e(s) <br /> L <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimus/TANK) d TANK(s)_ X 5234.00 = S <br /> S n l <br /> U TEMPORARY CLOSURE (Plan Review a Inspections) L`✓\ x ) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimmliACI� 4.00 minimus f <br /> INSTALLATION PLAN PLAN CHECK (Plan Review a Construction Inspections) TANK 1.0. 9(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = S78.00/hour (8 hours minimm/FACILITY) _ $624.00 minim f <br /> R REPAIR FEE (Workplan Review i Construction Inspections) TANK I.D. d(s) <br /> E <br /> P TANK LINING REPAIR FEE - S78.00/hour (3 hours minimum/TANK) 3 TANK(s) _ X 5234.00 = S <br /> A <br /> 1 TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE • f78.00/hour (3 hours minimum/FACILLTY) = $234.00 minimum i <br /> M TRANSFER FEE = S20.00 UMMMORIM RELEASE EVALUATION - $78.00/hr S <br /> I <br /> S <br /> C COMSLH.TATION PEE • $78.00/hr SAMPLING INSPECTION FEEr/ = 578.00/hr S 3 p� <br /> TOTAL OUE $ - <br /> FOR OFFICE USE ONLY <br /> SWEEPS s COMPUTER d LOC CODE DIST CODE AMCUNT RECEIVED CHECK S/CASH RECEIVED 3Y DATE RECEIVED <br /> EN 23 932 (REVISED,10-LB-93) /, Page <br />