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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> GROUND STORAGE TANK PROGRAM - FEE WORKSH <br /> S FACILITY SITE NAME FACILITY CWT NAME <br /> I 00(X FL hS fiSya ! -DAV iP7 5i✓7c.� <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & 73 )�, f/-PfFiL CLoSEl-) <br /> CITY � \\ ��StiTnAnTE ZIP CODE # of TANKS 2 <br /> A � r i?�%��N l�/� 17)$ Z-D-� at SITE ✓ <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L �S �s�i�LG�'�C.S /vC : �M11D 5/a CIN <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # NITH AREA CODE <br /> N <br /> Ii4� FrL'i i-4rJF 7 �- 3 <br /> 1q � - 3R4 n <br /> T CITY STATE ZIP CODE TYPE of APPLICATION 1 E�+P''R�n�Y <br /> � �A_ ,4 1� 9a 70� (Closure, Installation, etc.) <br /> J /�N TOTAL <br /> 1986 7987 7988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX XXXX XXXX XXXX S XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX S XXXXXXXXXXXXX <br /> I <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 17987 1 1988 1 1989 1 1990 1991 1992 7993 1994 1995 1996 <br /> F (muLtipty # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX I XXXX I XXXX I XXXX S <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks X $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> 5 <br /> C PERMANENT CLOSURE (Removat or Authorized Closure-in-P(ace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) aF SZ34.00 minimum S Z 3 CTo <br /> P INSTALLATION PLAN CHECK (P(an Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = 8624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.001hour (3 hours minimm/TANK) # TANK(s) _ X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = 5234.00 minimm S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr s <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> .__,._._..._..,._—,_...—��.__....._ —.._.__._ —.__..__.__ _ _.._... <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK 0/CASH RECEIVED BY GATE RECEIVED <br /> ii__......___.................. <br />