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SAN JOAQUIN COUISUBLIC HEALTH SERVICES ENVIRONMENTAL NEALT�IVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME r-- , / FACILITY CONTACT NAME <br /> T <br /> E FACILITY ADDRESS SITE PNONE 9 with AREA CODE <br /> Z <br /> CITYSTATE IIP CODE I of TANKS <br /> A at SITE <br /> P APPLICANT/SILLINo NAME APPLICANT CONTACT NAME <br /> C MAILING ADDRESS , /•� APPLICANT PHONE • WITH AREA CODE <br /> A x `7 <br /> N <br /> TCITYSTATE ZIP CDE TYPE of APPLICATION <br /> �-� 7 3 7 y CCI~S, In•tattatton, ate.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) ■ $100.00 1966 1967 19x6 1909 1940 <br /> A January � $ <br /> C <br /> t FACILITY PENALTY FEES ASSESSED (If Applicable) X10IX XKKK $ <br /> I <br /> V TANK FEE ■ $50.00/TANK (Prior to January 1,1991) $170/TANK (After Jarwry 1, 1991) <br /> E <br /> S Tsnha a 1966 1967 1906 1909 1990 1991 1992 1995 1941 1995 19% <br /> F (multiply 0 Wy fae for <br /> A each year oWticebte) $ <br /> C <br /> I TANK PENALTY FEES ASSESSED Kf00( 1000( $ <br /> L <br /> I STATE SURCHARGE ■ 556.00 each TANK (Due every S years) Sae California N i S Cole, Section 25287 <br /> T <br /> T 0 Tanks x 556.00 1986 through 1990 1991 through 19% <br /> (Enter smount and year) <br /> C PERMANENT CLOSURE (Renovat or Authorized ri ed Closure-In•Plaea) TANK I.D. #(s) <br /> )-- <br /> 0 CLOSURE FEE ■ S76.00/how (3 hours ninioAVTANK) 0 TANK(s) <br /> S —X 5232.00 <br /> U TEMPORARY CLOSURE (Plan Review i Inspectlo») TANK I.D. t(s) <br /> R <br /> E TEMPORARY CLOSURE FEE ■ $76.00/hour t3 hours MlnfuNFACILITY) a $234.00 Minimae S <br /> P INSTALLATION PLAN CNECK (Plan Review i Construction Inspections) TANK 1.0. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE + $76.00/hour (8 hours Minia WFACILITY) a $624.00 Minlima S <br /> R REPAIR FEE Workplan Review i Construction Inapsctiona) TANK I.O. R(s) <br /> E <br /> P TANK LINING REPAIR FEE + $78.00/hour (3 hours siniSMOANK) t TANK(s) X <br /> A 5234.00 ■ $ <br /> I TANK RETROFIT REPAIR FEE + $78.00/hour (3 hours min./FACILITY) • $234.00 Minissw S <br /> R <br /> PIPING REPAIR FEE + $78.00/hour (3 hours ninloWFACILITY) • $232.00 siniNus rlS <br /> N TRANSFER FEE • 520.00 UNAUTHORIZED RELEASE EVALUATION + S76.00/hr S <br /> i <br /> S <br /> C CONSULTATION FEE • $78.00/hr SAMPLING INSPECTION FEE ■ S76.00 $ <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY <br /> �t+ ��r"'i r`nr�r`Ti.iai■�i►anr.w����"ii�ww`■�ii.��.�i.`�iw'��wiTisi�w►w`C�■iT►iS riTi�i�■wwioi��Cw�ia'iSiiii:ijiA;iT� <br /> �,- 5V y vl $ <br /> ii3�ii�irwa'Tr�w'i.iwi� �Tiwr� �ww�rr��Tww+r�i■� w""i►� ■iws�iiis` .ww�ww w�irw�s�ra■�► <br /> liislle �a>taa�f�fa�N�M��MMAW�MAMM N ���afaXal�eNSaMw�aNN<RxAaw�����fa'a�M�����arrara•esrwsrwr <br /> EN 23 032 (REVISED 3.1-93) • Paea 11 -� <br />