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SAN JOAQUIN CC PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE DIVSION <br /> UNb,--R(UND STORAGE TANK PROGRAM - FEE W(IRKSHEEI <br /> S FACILITY SITE N �- �v , Ir <br /> ` 1 r FACI ITY CONTACT' NAME <br /> I �y. !t•. ..., tr�t�� ;:ro �y. r.,1+ , - ���, a,:� ,•�E1,ry*�!t 2t <br /> T <br /> E FACILITY ADDRE 5 SITE PHONpt.. ARERE�th CODE <br /> ,.,L / . <br /> CITY <br /> STATE ZIP CODE # of TANKS <br /> A at SITE <br /> P APP ICANT CONTACT NAME <br /> P LIC BI LING NAME <br /> �+ ,. <br /> L if'14 ✓ " ; '`'f'o` f,'+ I.1 Tw% L�� 1� YJ« �I��ft�,F`v <br /> I APPLICANT ON WITH AREA CODE <br /> A MAILING ADDRESS ©x I��f. 33 <br /> N f/ PPLICATION <br /> STATE ZIP CODE <br /> T CITYy fj y� (Closure Installation, etc.) <br /> �J TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 XXXX XXXX $ <br /> A <br /> CXXXX XXXX 5 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I <br /> $170/TANK (After January 1, 199 ) <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) <br /> E <br /> Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> # = <br /> F (multiply yy fee for XXXX XXXX 5 <br /> A each year applicable) <br /> C 5 <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T1991 through 1996 <br /> Y # Tanks x $56.00 1986 through 1990 <br /> (Enter amount and year) 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = <br /> STANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R5 <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> AS <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum <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 minimum/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 = 578.00/hr $ <br /> I <br /> S $ <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br /> TOTAL DUE $ <br /> _................:::-::::::::::::::--:-::::-:_:- ::-:_::_-:::-:-::::-:::;t— ==sat :ss::;::::• ---:— y <br /> F F I C USE ONLY _......_._..................__.....................,..::::::::::::::::::.::::.............................................:::::::::::::::::::: <br /> FOR 0 E ......1...._......_..._. .. .................:::-::::-:: ::::::::::::::::::::::::::::::::::::::::::::::::::::::.:._. <br /> ........................... ...........::•.......................................................: .............................................................. <br /> ........................... :..:::::•:::::::::::::::::::::::: :: :..............................::!:•::::-::•:::::::::::::::::::::::::........_.......... ..........................--......ili <br /> tt•. SLIEEPS # COh1PUTER aY LbC C00 •D1S CODE AMOUNI RECEIVED CHECK #)CASH RC�IV(D BY DAtE RSC VED <br /> ...._...... ::::wr.-:.--:.r.:::.^r..r.::-::n::r..-r..r.::r.:.'--::.r.. ...........i...._..—:r:_..........._. .... <br /> ::. ..... ..................._..._....M.....-s:�:::�::-....................::::: <br /> r. ..................................... ....... <br /> ................. .................................................................................................................................... .............................:::................................................:::::;:ttatatta:::::::::::_—�.::::::• <br /> :::::::::::::::::::.:.:.................................._.�...:.........: <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />