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SAN JOADUIN Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> U CUND STORAGE TANK PROGRAM - FEE WORKSNEE <br /> S FACILITY SITE NAME FACILITY CONTTT NAME <br /> T -lad ai. l-car✓' S i /I/at <br /> E FACIL TY A RESS SITE P ONE # 'th AREA CODE <br /> & u� . maw, d 0 6 L92 I <br /> CI TY& STATE ZIP CODE # of TANKS 3 <br /> Fat SITE p? ,1 <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> Go 1.Q <br /> C MAILING ADDRESS APPLICANT HONE # WITH ARE CODE <br /> V17- <br /> A <br /> N <br /> T CITY / STATE ZIP CODE f APPLICATION '- 4 <br /> � �, / (Closur i Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1986 1987 1988 1989 1990 <br /> A XXXX XXXX XXXX x%XX XXXX $ XXXXX%XXXXXxX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX %XXX $ xXXXXXXx%XXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/ K (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 991 1992 1 1993 1994 1 1995 1 1996 <br /> F (multiply # by fee for <br /> L each year applicable) Xx%X XXXX XXXX XX XX%X 76 O Il ID O S 'TVA D <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX Xx %XXX <br /> L X%%% �O b A V DAL) <br /> j��O <br /> T STATE SURCHARGE = $56.00 each TANK (D every 5 years) See California H & S Code, Se on 25287 S <br /> Y # Tanks x $56.00 1988 through 1990 19912 <br /> 991 ough 1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D #(a) <br /> — <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TAN X $234.00 = $ <br /> 5 r!yN� � <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) A I.D. #(s) �Sl -7060 S, /YI.00.�t <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minima /FACILI Y) $234.00 <br /> mi 'nun C S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> Ni PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours mini mum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr $ <br /> 5 <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr $ <br /> TOTAL DUE S O <br /> FOR OFFICE USE ONLY <br /> IlCiilll.111111111.IL1:.:.:.:............_.._...:v.x[:.::::.[I.:::L:::..::wvi[Sa_u..:..i.::::.._._..._...v.::::::::...�..:................................_...:.......:�::::-:::::::::::_::::���e::::=_::::::::::::::e::....�......._.....,..._..........................._........._..................._._.... <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> S <br /> ........................................................................................................................................................._...........__............::::::::::...,_::::::::_:-:::C::[:[::::::::.::::-:__.�:.-:::::::--,::: <br /> ..............:::::::...... :!: :::::!!!!!!!!::!!!!!!!!!!!!!!!!:!!:!!!!::-:!M...... ......................................................................_..._.._....._........ ,................:.._!:.::::_::::_�::::�:............................................................. <br /> .................................. :::::::!!!!!!!_!!!:::::::::::::::::::::,::::::::::::......................................_.... m: !_ma!:m-.=.:_!!!_a!!!!!!__;:�__......_.... ......._........................ . <br />