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SAN JOAQUIMTT PUBLIC HEALTH SERVICES - ENVIRONMENTAL N DIVSIOM <br /> i qWRKS <br /> GRQRID STORAGE TANK PROGRAM - FEE WONE�T <br /> S FACILITY SITE NAME gZIP <br /> CILITY CONTACT NAME <br /> I <br /> T - <br /> E FACILITY ADDRESS TE PHONE # with AREA CODE <br /> & /�f S f <br /> CITY rA P APPL(C T/BILLING NAME PLICANT CONTACT NAME <br /> L <br /> C MAILIN DORESS APPLICANT PHONE # WITH AREA CODE <br /> N ©. �- <br /> T CRY (-` { / - TVT STATE ZIP CODE TYPFtLLo of APInstalI , rJ�p�� _- <br /> �.J\ /uLosure Installation, ate.) Il/r`^�"� <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1997) = 5100.00 1986 1987 1988 1989 1990 <br /> C <br /> On--11 x /.ca /00 <br /> 7I FACILITY PENALTY FEES ASSESSED (If Applicable) Q (Gd (C,0 5 3 d D <br /> I <br /> V TANK FEE = 850.00/TANK (Prior to January 1,1991) ury 1, 1991) <br /> E <br /> Tanks = 1986 1987 1988 1 1989 / 4 1995 1996 <br /> F (mul[ipLy Al fee for ` („� <br /> A each year applicable) S0— <br /> ©— � <br /> C Q <br /> �) I <br /> I EANKPENRALTY FEES ASSESSED XXXX XXXX 6U' �LHARGE = 556.00 each TANK (Due every 5 years) Section 25287 <br /> T <br /> Y *Ian' x $56.00 1986 through 1990 1991 through 1996 <br /> (Entamount and year) <br /> gL I `J�1 SCc $ I <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = 5 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimun/FACILITY) _ $624.00 minimum S <br /> RI REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimim/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> 1 TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $734.00 mini mm $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum 5 <br /> MI TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> S <br /> CCONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = $78.00/hr q <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> .v.=--=•n...•cuiuiiiuiiLimi"v':-••:.•..--=-c''_i[uuri'u-;i:iu�eu'uuii'uF:i:i3i::::::m <br /> SWEEPS # I COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED I CNECK #/CASH RECEIVED BY DATE RECEIVED <br /> EH 23 032 (REVISED 11-1-92) Page 11 'z <br />