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~ • SAN JOAOUIN COUW BIIC HEALTH SERVICES - E]1viR010E1fTAL HEAL IVSION <br /> UNDE l0 STORAGE TANK PROGRAM - FEE WORKSHEET <br /> QTY SITE NAME <br /> FACILITY CONTACT NAME <br /> r Janne <br /> ITY ADDRESS SITE -PHONE # with AREA CODE <br /> 922 0297 <br /> t STATE ZIP CODE of TANKS <br /> ►ICh cam �a 23 at SITE threp <br /> CANT/BILLING NAME APPLICANT CONTACT NAME <br /> tMarket <br /> MG ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> ,5 South ElDorado Street 209 82 897 <br /> STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> r <br /> 1986 1987 1988 1989 1990 <br /> FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> XXXX XXXX (XXX S <br /> ITY PENALTY FEES ASSESSED (if Applicable) X000( X)00( xxxx S <br /> FEE = $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> S 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> ply Y-By—fee for <br /> ear applicable) (XXX (XXX X000( 5 <br /> PENALTY FEES ASSESSED (XXX XXX)( X000( S <br /> SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> s x $56.00 1986 through 1990 1991 through 1996 <br /> & amount and year) <br /> t 5 <br /> GENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> IE FEE = $78.00/hour (3 hours minita/TANK) # TANK(s) X $234.00 = S <br /> IARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> GARY CLOSURE FEE = $78.00/hour (3 hogs minimum/FACILITY) $234.00 minimum S <br /> ;LATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> f � <br /> ;HECK FEE = S78.00/hour (8 hours miniaa/FACILITY) $624.00 minimum S <br /> ( FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> ;INING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> JETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = SZ34.00 minimum $ <br /> i REPAIR FEE = S78.00/hour (3 hours ■inieua/FACILITY) $234.00 minimum - S <br /> IER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr L til, C 2a 53 9 p <br /> DATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr j e Gb (0 7'a L S <br /> I TOTAL DUE S <br /> 4lS�QM.4.T_= <br /> ' — i <br /> CbMPUT1°R�' LbC'�od��Ul�6€�a7A1'`k��E1C1E6"T�H��K�t7CA�ll-- R�tEC4�l5 9 �AT�—k�•�ETvED . ;�i <br /> $ <br /> G (REVISED 4-29-94) Page <br /> F <br /> eyF <br /> S <br />