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ACILITY SITE NAME <br />c FACILITY ADDRESS <br />r <br />1989 1990 <br />1 <br />PTY <br />A <br />llP <br />S <br />P <br />APPLICAN BILLING 1 <br />L <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum <br />I <br />ivalino <br />C <br />MAILING ADDRESS <br />A <br />FACILITY PENALTY FEES ASSESSED (If applicable) <br />Mf— <br />I <br />R <br />T1 <br />CITY <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIV ION <br />UNDER STORAGE TANK PROGRAM - FEE WORKSHEET <br />FACI CONTACT N <br />rJ- SITE PHONE # with AREA CODE <br />ZDV -r Z ... 'Zn <br />STATE ZIP CODE # of TANKS <br />. at SITE <br />r APPLICANT CONTACT NAME <br />APPLICANT PHONE 9 WITH AREA CODE <br />5 114-141-R.331-51 <br />STATE ZIP CODE TYPE of AP <br />(Closur , installation—,,,etc.) <br />ICI PERMANENT CLOSURE (Removal or Authorized Closure-in-P(ace) <br />TANK I.D. 1(s) <br />TOTAL <br />0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br />S <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) S100.00 <br />1986 1987 1988 <br />1 1 <br />1989 1990 <br />1 <br />TANK I.D. #(s) <br />A <br />5234.00 minimun <br />S <br />P <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. X(s) <br />C <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum <br />XXXX XXXX I <br />R <br />E <br />$ <br />T <br />FACILITY PENALTY FEES ASSESSED (If applicable) <br />XXXX I XXXX <br />I <br />R <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br />I <br />I <br />( <br />S <br />V <br />TANK FEE = $50.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br />F <br />0 Tanks = <br />(multiply X by fee forI <br />1986 <br />1987 <br />1988 11989 <br />1990 <br />1991 1992 11993 <br />1994 11995 11996 <br />A <br />each year applicable) <br />XXXX <br />XXXX <br />I <br />I <br />C <br />I I I <br />S <br />I <br />TANK PENALTY FEES ASSESSED <br />I XXXX <br />I XXXX <br />L <br />I <br />S <br />I <br />STATE SURCHARGE = $56,00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T <br />T # Tanks x 556.00 <br />1988 through 1990 1991 through 1996 <br />(Enter amount and year) <br />i <br />ICI PERMANENT CLOSURE (Removal or Authorized Closure-in-P(ace) <br />TANK I.D. 1(s) <br />TOTAL <br />0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br />S <br /># TANK(s) X 5234.00 = <br />s <br />U TEMPORARY CLOSURE (Plan Review & Inspections) <br />R <br />TANK I.D. #(s) <br />E TEMPORARY -CLOSURE FEE = S78.00/hour (3 hours minima /FACILITY) <br />5234.00 minimun <br />S <br />P <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. X(s) <br />A <br />N <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum <br />S <br />R <br />E <br />REPAIR FEE (Workplan Review & Construction Inspections)I TANK [.D. #(s) <br />P <br />A <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = <br />f <br />I <br />R <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br />S Z /� �'1 <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum <br />s <br />Mj TRANSFER FEE = 520.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I I S <br />I <br />S � i <br />C CONSULTATION FEE - 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr S <br />TOTAL DUE S Z �' <br />F01 IFFICE USE ONLY <br />,WEEPS X I COMPUTER # � LOC CODE I DIST CODE AMOUNT RECEIVED CHECK k/CASH I RECEIVED 3Y I DATE RECEIVED <br />S <br />GH 23 032 (REVISED 10-28-93) 3 <br />G <br />Y <br />