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F/P 71'7 <br /> 7gad <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVSION I fP 7I/ <br /> U.. RGR=L STORAGE TANK PROGRAM - FEE WORKSHEE <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T _ SltiJ s �J t40Z S E N O e) <br /> E FACILITY ADOR SS SITE PHONE X with AREA CODE <br /> , ,� 5�9 _ <br /> s ,�yy,, Y !J _ 5 STATE/� Z1�1 <br /> CITY j �'rCJ' 7�� V �J'v `� /P� 3EC b at SITENKS <br /> A <br /> P <br /> PAPPLICANT/BILLING NAME APP ICANT CONTACT N <br /> L 0 Sf.)'s eJ(ZI S'r I 2 Y Yl f4 <br /> C NAILING ADDRESS APPLICANT PHONE X WITH AREA CODE <br /> A 3� C�� b 3 <br /> T CIS7TA,y���/'))) TATE ZIP CODE TInsYPE of APPLICATION <br /> I"I!JQ S 3 (Closure, tallation, etc.) <br /> l� TOTAL <br /> 1986 1987 1988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX s <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX XXXX S <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> S Tanks = 1986 1987 1988 11989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply d -by fee for I ✓ <br /> A each year applicable) XXXX XXXX <br /> LI TANK PENALTY FEES ASSESSED I XXXX %XXX I I 5 <br /> I STATE SURCHARGE = 856.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 /( <br /> TY d <br /> Y x Tanks x 856.00 1988 through 1990 1991 through 1996 -, --� <br /> (Enter amount and year) - �6 <br /> I FF <br /> / 6 $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. l(s) <br /> L <br /> O CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) X TANK(s)_ X 5234.00 = 5 <br /> S <br /> U TEMPORARY CLOSURE (P(an Review & Inspections) TANK I.D. i(s) <br /> R 5 <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/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 = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minima s <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. N(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I 9 TANK(s) _ X 8234.00 = S <br /> A S <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minima <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minima s <br /> MI TRANSFER FEE = 520.00 I UNAUTHORIZED RELEASEE EVALUATION = 578.00/hr s <br /> I <br /> S g <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br /> TOTAL DUE s 6 7 <br /> OR OFFICE USE ONLY ..__.. _._... <br /> ...._....__. _ ___..____..._....._.__.__...._._._........__.__._..___._ --_::_-._..:: .. ........................_.........._....._....___._.._..._..........._........___ <br /> :�WEcPSRCOMPUTER 7 LCC CODE DIST CODE AMOUNT RECE CUED I CHECK R/CASH RECEIVED BY DATE RECEIVED = <br /> ,-:_:::_._ <br /> EH 132 (REVISED 10-28-93) -- Page 11 <br />