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SAN JOAOUIN COUP PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEAt—DIVSION <br /> UND%,,.GUWD STORAGE TANK PROGRAM - FEE WORKSHEET <br /> I S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I Al GA - -,, 7`c� J� [i u U �. c e f 4,- <br /> T <br /> E FACILITY ADDRESS - SITE PHONE # with AREA CODE <br /> CITY STATE ZIP CODE # of TANKS <br /> A .S&- c./c /t- �-z G-+ at SITE <br /> l P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT H E <br /> L J&/ a, '-- c <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # W TH A EA CODE <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION C,4 <br /> 6 (Closure, Installation, et ) 11,pa-o._C1 <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A <br /> � oo /0,) 16,0 S ou <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX O Iva /U() S O U <br /> I <br /> V TANK FEE SSO.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> N Tanks = .Z 1986 1987 1988 1989 1990 1991 19921493 T994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) y <br /> I TANK PENALTY FEES ASSESSEDXXXX XXXX fo f0v OD �y��3`�—�3Y� <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks_-,—)—x $56.00 1986 through 1990 1991 through 1996 _ <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.O. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 2234.00 = y� <br /> S / <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 278.00/hour (3 hours minimum/TANK) # TANK(s) X 2234.00 = S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 278.00/hour (8 hours minimum/FACILITY) = 2624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> L't- <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S Ou, <br /> I \ <br /> S 1 <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> ...._..........._.. _...... ..._.._..... _......................._..............._.__...- _._._._._.....__..._—_..........__ _..._.._. ......... <br /> ::......_..._..._...-...._......_.._. ......... _.._...:_: --- --- - - <br /> /'S 5ps-0 C PUTEA # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> 3 Z3 s <br /> :...._................_ _. ._ _ __ v — <br /> __....._._.._.. ._._..._...._....._ ................_ <br /> _....._ .._._....__.____... <br /> -=-M.....__..__.._..._.._........ <br /> .........__.___.._...___._._...._ _ ._._......____.__. __.........___......__...___.._.....__..- ._..........:.._._..----_.........: <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />