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SAN JOAQUINPUBLIC HEALTH SERVICES - ENVIROIDIVSION Z" J <br /> &GGROUND STORAGE TANK PROGRAM - FEE WCRKSHEE <br /> FSFAI,CILITY SITE NAME FACILITY CONTACT NAME <br /> SILIGC k h�� SITE PHONE # with AREA CODE <br /> ILITY ADDRESS <br /> g{'b ft,6E PJ U£ <br /> A STATE ZIP CDCE # of TANKS <br /> C[TYn0 d' /'A. Gat 517E <br /> A <br /> P <br /> Vu-7- <br /> CONTACT NAME <br /> P APPLICANT/BILLING NAME Vi-r vFr- <br /> L 51rCo <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A fLI'P S, � S . CZ <br /> N <br /> T CIT ATE ZIP CODE TYPE of APPLICATION <br /> ,� /O�£ . -6 CI- CP-1 (Closure, Install tion, etc.) �zA,C(7�d(L <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 S <br /> A <br /> Dxxxx xxxx 5 <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) <br /> I <br /> V TANK FEE = 550.013/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> ETanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> = <br /> F (multiply #by fee for S <br /> A each year appLicable) <br /> I <br /> I TANK PENALTY FEES ASSESSED XXX% %XXX S <br /> L G <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T1 <br /> Y : Tanks z $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) S <br /> I <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-P Lace) TANK I.D. #(s) <br /> L = 2 <br /> ZS <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X 5234.00 - S 2 3 <br /> 5 <br /> U TEMPCRARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) �V <br /> Ei TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimtm/TANK) # TANK(s)_ X 5234.00 = S <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 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> ES <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minima ITANK) # TANK(s) _ X 5234.00 = <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) $Z34.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> E <br /> S <br /> C0NNSLILTATICN FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> SWEEPS # I COMPUTER # I LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK #/CASH I RECEIVED BY I DATE RECEIVED _ <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />