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3-26-1997 9:55AM FROM P. 10 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIPOUNIENTAL NEA H DIVISION <br /> UNOERGRCIM STORAGE TANK PROGRAM • FEE WORKSHEET <br /> S FACItfTY SITE NAME FACILITY CONTACT NAME <br /> I k a <br /> T <br /> E FACILITY ADDRESS SITE PHONE Yttl AREA CODE <br /> & <br /> CITY STATE Z P CODE 5 of TANKS <br /> A at SITE <br /> P <br /> P T 8 LLNQ NAME AAP I NT TACT E <br /> L I f <br /> I <br /> C MAILING ADDRESS APP 1CANi NE # WITH AREA CCOE <br /> en <br /> K i— =� <br /> T C1 Y STATE ZIP CODE TYPE of A2!�� <br /> ( (Ctasure, tc.) <br /> �7 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 5 XXXXXXXXXXxxx <br /> C <br /> T ~AGILITY PENALTY FEES ASSESSED (If Applicable) XXXX Xxxx XXXX XXXX XXXX S XXXXXxxXXXXXx <br /> I <br /> V TANK FSE = $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> Y Tanks = 1956 1987 1 1988 1989 1990 1991 1992 r 1993 1994 1995 11446 <br /> F (rm,itiply 0 by fee for <br /> A each year applicable) XXXx xxxx XXXx XXXX XxXX $ <br /> C <br /> `i AN PENALTY FEES ASSESSED I XXXX Xxxx XXXX XXXX XXXX S <br /> i STATE SURCRARGE = 556.00 each TANK (Due every 5 years) See California H & S_ Code, Section 25287 <br /> T <br /> Y X Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Pisce) TANK I.D. S(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) X TANK(s) X 5234.00 = 5 <br /> S TANK I.D. e`W <br /> U TEMPORARYv CLOSURE (Plan Review & Inspections) <br /> R <br /> E TEMPORARY CLOSURE FEE z 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (PLan Review & Construction Inspections) PANK I.O. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours mini muWFACILITY) : $6224.00 minimum Fs <br /> ql REPAIR FEE (workplan Review & ConstructicA Inspections) TANK I.D. kk(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) 0 TANK(s) X $234.00 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = 5234.00 minim= 5 <br /> MI TRANSFER FEE = SZ0.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr $ <br /> I i <br /> $ <br /> C CONSULTATION FEE - S78.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE S <br /> TT <br /> _FOR OFFICE USE ONLY <br /> .•,n ,wl.L,es!namHt:asamalNnmunntrm « � •:« ,• i! <br /> !>:u:l...—'..h.3'.• 1�NNIn1UNN:L4i1T;T::ftn:l:l::tt.•IR.:'.T.S:T..:t3::.T.S....FC-=•'.:::C::G_^........".._"mm' 'n:.^�.... f!j .. 1•�I.J���1 �• ..y»...... .. �':««.'•«5:3'«...... <br /> ........»......»......_................ .........................:J.:.._ <br /> SEEPS x COMPUTER 0 LOC COOS f DISI CODE AMOUNT RECEIVED { CHECK N/CASH RECEIVED BY DATE RECEIvED <br /> r <br /> ..r. . ..r. «« <br /> eie::r.:r.�:-.«.;.:::.«:... .�... N r•••t_ ... .......cam:t»rrr..:nrc•��••..•:•.a::.^^:a..........._ . <br /> ..........._......._c...r..i i i r r ._...... ;.r.._ _:«.....»..____._........:r'�•• n� .�: , �'�.. rlMrnunw-::5:�::.:-:::E::mr.:«:�:.::::e:'s?�.•rmr`7i�m �l�r!:• � -n._LC._S�Fr.L.'�.ara:s:�.lf�n• <br /> _..«..,._..:_ :..... ,• .. u ...___.:r. _..._._._ �::::=::«.... .—_.__.. 1111N�' - <br /> :s:.ratehrr.::::Y7::riuw1itt71i17G1"'e:f:.:!L!.::...__..::iiiiSi-:_•�;.��.•::«• _..._.�..-.::r.:.-...-::.......�x:!3ia»iiW�C�.�...4�tlRitbi(4Eiui:ice."r.:::-art::=�e..r..n.u.wrSW •Nyx�=• .a <br /> .;c......... Nwn:n auac�^M.:r^:. <br />