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L-9\L <br /> SAN JOAQUIN 'TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL --'LTH DIVISION <br /> U1 ROUND STORAGE TANK PROGRAM - FEE NORKSHEE <br /> SF`.ILIT►• SITE NAME FACILITY CONTACT NAME <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE _ <br /> CITY n�y STATE ZIP CODE # of TANKS _l <br /> A `�'tW� 1 I�CfI` at SITE <br /> P <br /> P APPLICANT/B.ILLING NAME APPLICAJNT CONTACT NAME <br /> I �Co �om�v, rr< t2 <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> w, 1 _ ? l Sia 1 %`kS— X33 <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> } (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX I XXXX XXXX XXXX $ XXXXXXXXXXXXX <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX I XXXX I XXXX I XXXX I XXXX $ <br /> L <br /> I STATE SURCHARGE = $56.00 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 /> $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> EI TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY)7$234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ <br /> RI REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> MTRANSFER FEE = $20.00 I UNAUTHORIZED RELEASE EVALUATION = $78.00/hr I $ <br /> I � <br /> S' <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY <br /> ... _... ._....._.......=–_� __.�_:_._-- ..-..__ � :..._.._:_._:.._:..._..._.._..----- .—.._.._...____..:__._._._�._..�....__.___ ..---._._....__.._.._........_........... _ <br /> SWEEPS # I COMPUTER # I LOC CODE DIST CODE I AMOUNT RECEIVED I CHECK #/CASH I RECEIVED BY DATE RECEIVED = <br /> :........_....................................._.......__.._...-- ..1.........__........----.....1............_......_.._...._......1.__$................ : _� :::1.:: ::::::-: -. F <br />