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SAN JOAOUIN C1 ORLIC HEALTH SERVICES - ENVIROIOIENTAL( DIVSION <br /> Lo. ..RGROU110 STORAGE TANK PROGRAM - FEE NORKSHEk.. <br /> S.�7T SITE NAME FACILITY CONTACT NAME <br /> I <br /> T <br /> E FACILITY ADDRESS I SITE PHONE 9 with AREA CODE <br /> & 5 Q I A <br /> CITY STATE ZIP CODE C of TANKS <br /> PI I C I at 527E <br /> P+ APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> Cl MAILING ADDRESS APP CANT PHONE VITH AREA CODE <br /> AIZ S` w U �\ 3 - 4 <br /> N <br /> T CITY I STATEj� CODE I TYPE of APPLICATION <br /> tc.) <br /> U L t� (Closure, Installation, <br /> TOTAL <br /> i 1986 11987 11988 11989 � 1990 I <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A mcccIX)= I = I IS <br /> TI FACILITY PENALTY FEES ASSESSED (if Applicaole) I =0( I ==XX I XX== I I S <br /> I I <br /> Vi TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E' <br /> ! TanKs = )C (7�c i 1986 11987 11988 11989 j 1990 11991 11992 11993 11994 11995 11996 <br /> FI (muttiply s by fee for / <br /> Al earn year applicaOtt) XX=X I XXXX I KXXX I I I I I I I I I S <br /> CI TANK PENALTY FEES ASSESSED I XXXX I =XXX I )0XX= I I I I I I I ( S <br /> L <br /> II STATE SURCHARGE .00 each TANK (Due _very 5 years) See California H & S Code, Section 25287 <br /> TC <br /> Y1 .1Tanks 7 z SS ,�"�� I 1988 through 1990 1991 through 1996 <br /> (Enter amount ar)Ei year) <br /> S `, <br /> j I 7 i <br /> Ci PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) I TANK !.D. a(s) <br /> L: <br /> 01 CLOSURE FEE a 578.00/hour (3 hours minimum/TANK) 9 TANK(s) X 5234.00 = I S I <br /> Si f <br /> UiTEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. :(s) {i <br /> R) <br /> Ej TEMPORARY CLOSURE FEE * S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimus I S I <br /> P� INSTALLATION PLAN CHECX (Plan Review & Ccmr ruction Ins0e=i0ns)I TANK I.D. .'(S) <br /> Ai <br /> L I <br /> NI PLAN CHECX FEE = S78.00/hour 1.8 hours minimus/FACILITY) 5624.00 minis.= S <br /> RI REPAIR FEE (11orkplan Review & Construction Inspections) I TANK I.D. :(s) <br /> E; <br /> P} TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I 0 TANK(s) X 5234.00 = S <br /> A I <br /> II TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) a 5234.00 minimus S <br /> R IPIPING REPAIR FEE = 578.00/hour (3 hours minimus/FACILITY) = S234.00 minimus S I <br /> MJ TRANSFER FEE * 520.00 I I UNAUTHORIZED RELEASE =VALUATION = S78.00/hr I I S <br /> C CONSULTATION FEE = S78.00/hr I rI SAMPLING INSPnECTION FEE v = 578.00/hr I I S <br /> r1 G �l�`� 3 � �' i ItiSI�--1�'C — C�-vim CJS 1,� I j �o •GX� _ TOTALS S <br />=FOR OFFICE USE ONLY c a li' OU c°� o�I sC�) !-/ I r� C(; 1 <br /> SWEEPS I COMPUTER LOC CODE I DIST =E I AMOUNT RECEIVED i CHECX =/CASH I- RECEIVED 3Y j DATE RECEIVED <br /> Is I I I <br />