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SAN JOAQUIN WWY PUBLIC HEALTH SERVICES - ENVIRONMENTAL H H DIVISION <br /> U ND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONWT NAME <br /> I <br /> T <br /> / va � !'varJ <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> I Z Z 5 a-/esT 2oGY - ,3 . - /U3e-' <br /> CITY STATE ZIP CODE # of TANKS 'F— <br /> 'A <br /> Z'A / at SITE <br /> P <br /> P APPLICANT/BILLING NA APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> AG `c2 tJIJ fLo - Lo'� - 212 <br /> N <br /> T <br /> STATE ZIP CODE TYPE of APPLICATION <br /> i- c (2 151'L (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 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 = '2— 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 $ q C <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S_ Code, Section 25287 <br /> TL►u)"c 30!089 <br /> Y # Tanks x $56.00 1988 through 1990 1991 through 1996 p�b& D <br /> (Enter amount and year) <br /> CPERMANENT 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 /> 11 E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/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 = $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 /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ <br /> TOTAL DUE $ 2 6, <br /> FOR OFFICE USE ONLY <br /> ...................:.:.::.::.::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::-:::...:...................................................................................................................:...:_:..:::::::::::::::::::: <br /> ................................................-. ......-:..........................................................................................................-:......................:.................................................................................................................. <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> 9 <br />