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SAN JOAOUIN A PUBLIC HEALTH SERVICES - ENVIRONMENTAL AN DIVSION D <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSIIEET <br /> S FACILITY SITE NAME J�CODE <br /> TY CONTACT NAME <br /> I cl-rq 6,C GOD1' v6 Vitte <br /> T <br /> E FACILITY ADDRESS HONE # with AREA CODE <br /> A /Z5 yvo2zy Saaez��v sze<c79 :5-138 <br /> CITY tATE <br /> # of TANKS J ENVIRONMENTAL HE <br /> A LOD/ at SITE PERMIT/SERVICES <br /> P APDLICANT/BIILIN1> " ICA ACT NAME <br /> N <br /> L F"'��!! /!/ <br /> C MAILING ADDRESS CANT PHONE # WITH AREA CODE <br /> N �3� W f ht���i /�4n ZV9 5Z 96 <br /> T CITY TYPE of APPLICATION 1?rIn "I'tLL/V?O,OESZtl i (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> t <br /> A <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %%%% %%%% % <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply R—by fee for <br /> A each year applicable) 5 <br /> C <br /> I TANK PENALTY FEES ASSESSED KX%% XXXX 5 <br /> L <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H R S Code, Section 25287 <br /> T <br /> T # Tanks z 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S 03'f4 DO <br /> S <br /> U TEMPORARY CLOSURE (Plan Review S Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE 278.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 S <br /> Pi INSTALLATION PLAN CHECK (Plan Review b Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours m(nlmum/FACILITY) = 5624.00 mini" 5 <br /> R REPAIR FEE (Workplan Review 6 Construction Inspections) TANK I.D. #(a) <br /> — <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) # TANK(s) _ X $234.00 5 <br /> A <br /> 1 TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE 578-00/hour (3 hours minimum/FACILITY) $234.00 minimum S <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr S <br /> .L TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> almilxillixi:xm!IF�x <br /> /JY � .mxrmmi ,xmmnvmrxa <br /> 3Fi"!ixv!x.^.liximlixixxlim:mlxmxmlm@mx!Dim xmxxMIMMIixix mCxmmm�mfilimixlAn^m�mnm nnnsmmmamxmmtAxlmmmmmmm�nnmli!i�mmm:!nlmm�mmmmm�nmcliP� <br /> ..:,rl'm;am!lalimnnnnnmr;nm;mn;or�i rna!;vra;mmnxnm!m;nxmm�mm�mxm;nnmrunl;n!Illllllnnnx;t�i!inutuunxnn;nn!nux!;nmmmm�nmmnnnnunnrnnmamnm;unnnnmmum!xmmnn;nnmmnx�iv;nmmnnxmm;xnnx;uarx;mx!;e+� <br /> m SWEEPS #, COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> m <br /> ]i <br /> Q <br /> � <br /> ' ..:_:..,.:...........!......_.....:....: I..r;.;iVs..Imm!` <br /> nm.!n.„.mu rTmxmx:.s�manm � u...:..T.w. <br /> m... �.. .m,.x�mnnuunmm�mini 1111191nnm!,u.. . rxe3jm,n�•anmr-�;,.nM,.�nfnnn•,;m,!..xm!nx!IiI:!:!mxmmm!n�;!:u.ninmnmm�mnemr:u;xmxm;n�nmmixm;n;xennm;;;;_::;x!I;t;//t;;mn''6!jjnmnlm�m;; <br /> x�;!anmsT;tx�i n!nm <br /> imr::rxaamu!x:! <br /> tn <br /> tt. <br /> EN 23 032 (REVISED 11-1-92) Page 11 <br />