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i <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND NSTORAGENTAL TANKHEALTH PROGRAM I- FEENUORKSHEET <br /> F FACILITY SITE NAME FACILITY CONTACT NAME <br /> A5 L&fn f-/v s vice c� R CSB Hf of <br /> C <br /> I FACILITY ADDRESS ITE HONE # with AREA CODE <br /> ZL 7- 7Ta Ls z 7 Z� 71Z 3 <br /> T CITY STAAnTE ZIP CODE # of TANKS <br /> Y cS v� Cn Z67 et SITE <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> I NAILING ADDRESS <br /> A N /l C. Y /1 f�v PPL CANT PHONE #?LTH AREA CODE <br /> T CITY C�� KlST TE ZIP�c�yOOE APPLICATION <br /> �✓" C j & 2-] CLOSUR INSTALLATION, etc. <br /> A 10TAL <br /> C 1986 1987 1988 1989 tong <br /> T ANNUAL FACILITY FEE (Prior to January 1, 7991) = SlGO'OO <br /> 1 <br /> V N S <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) S170/T <br /> F # Tanks = 1986 1987 1988 ea 1989 1990 1991 rT`J c/q'(•' <br /> A multiply yifee for <br /> C each year ppl icebl e) <br /> 1 E <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California <br /> T # Tanks x 556.00 1986 through 1990 <br /> r (enter amount and year) <br /> t <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in TANK LD. <br /> C _ <br /> L CLOSURE FEE = S53.00 per hour (3 ho Fs minimum per TANK) # TANK(s). -Z X 2159.00 = 5 <br /> S — <br /> U TEMPORAR mime permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARYCLOSURE FEE = S150.00 each TANK # TANK(s) X 5150.00 = 5 <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum S <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. #(S) <br /> E <br /> P TANK REPAIR FEE = 553.00 per hour (3 hours minimuv/TANK) If TANK(s) X $159.00 = 2 <br /> A <br /> 1 <br /> R PIPING REPAIR FEE $53.00 per hour (3 hour minimum per facility = 2159.00) S <br /> M TRANSFER FEE E20.00 MM7MHEq <br /> 53.00/hr 5 <br /> 1 <br /> ClCONSULTATION FEE 553.00/hr 3.00/hr <br /> TOTAL DUE <br /> OFr,ICE.USh.,;oN;(,Y <br /> Loc Coo E- oliY coliE AHb�IAT'�kCvD ..... ....'L;g <br /> _ K CASH <br /> R)L�E I <br /> ....�mx !_. M.5' <br /> v: +::—�:r!;=__.--_=_e:�=moi'='isnv,-:.E:_:::t2:v=;v�:i;_v ,,....,...,...._....... ....... <br /> EH ZT-1S�(RE i -E, ....._:_.v!�y,!::_:_a! :-__ :as <br /> 4/8/91 ft Page 11 <br /> �� 57��<< Z.Z <br />