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SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES - EXVIODNENTAL HEALTH O(VSICW <br /> STORADE TAXK PROGRAM - Fe= WORKSHEET Ank <br /> SI FAC TY SETE NAME i fA ITT CONTw HANE <br /> T (feu W(1i4,L WA; i 1�Q u,ZA <br /> E FACILITY ADDRESS SITE NORE t With AREA CODE <br /> a Ngo W Atm a :). ©n <br /> CITY /nS�TA1E ZIP CODE tot TANKS <br /> A 01A Ar,, l'a 9S h at SITE <br /> P — <br /> P APPLE CAN T/OILLING NAME APPLICANT CONTACT NAME <br /> L �7 M <br /> C NAILING ADDRESS APPLICANT PHONE It WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE I TTPE of APPLICATION <br /> (Closure, Instattation, etc.) <br /> TOTAL <br /> 1 1986 1987 ' 1988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A I XX%X I KX)OC I S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I xxxX I X)= I I 5 <br /> I <br /> V TANK FEE 550.00/TANX (PHOC to JatxAary 1,1991) S170/TANK (After January 1, 1991) <br /> E <br /> 0 TankS e _ 1986 1987 1988 11989 11990 i 1991 1992 11993 1994 1995 11996 <br /> F (nultioty t by tee for <br /> A each year appliGahle) KKKK KKKK I I I I I t <br /> C <br /> I TANK PENALTY FEES ASSESSED XXID( x;= I I I S <br /> L <br /> 1 STATE SURCYARGE = $56.00 each TANK (Due every 5 Years) See California N S S Code, Section 25287 <br /> T <br /> V 3 Tanks_ x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amo7t and year) <br /> S <br /> C PERMANENT CLOSURE (Ramoval or Authorized Ctasure-in-Ptace) I TANK I.D. a(s) <br /> L <br /> 0 CLOSURE FEE - S78.00/hour (3 hcur2 allnimAa/TANX) t TAXX(s),,,,,,,,,. X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (P(an Rav(aw i trsspeetiora) TANK I.O. s(S) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours mini&JWFACILITY) $234.00 minimlAa S <br /> PINSTALLATION PLAN CHECK (Plan Review 8 Consiructim Inspections) TANK I.O. t(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours miniaxm/FACILITY) = 3624.00 mimi S <br /> R REPAIR FEE (Workplan Review R Construction In=ecticau) TAXK 1-0- i(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) 2 1AXX(3) X 5234,00 = S <br /> A <br /> TANK RETROFIT REPAIR FEE - S78.00/hour (3 hours min./FACILITY) 3254.00 mi nicua S 3y�� <br /> PIPING REPAIR FEE = S78.00/hour (3 hOUrS minimLo/FACILETY) 134.00 miniaaet S <br /> 3 <br /> NI TRANSFER FEE = S20.00 I i UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I S <br /> t <br /> S � 1 <br /> C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 57H.0)/hr I 3 <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> SWEEPS 4 COMPUTER f LOC CODE I O(ST CODE 1 AMOUNT REL-EIVED C:.ECK d/CISH I RECEIVED 3Y DATE ZECE(VEO 3 <br /> mwZ;eiuls_". <br /> EH 23 032 (REVISED f0.28-03) 3 <br /> Ti iTHI_ F'. I <br />