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SAN JOAQUIN PUBLIC HEALTH SERVICES - ENVIRONMENT �TN DIVSION <br /> GROUND STORAGE TANK PROGRAM - FEE SiIEE� <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> FLT <br /> E FACILITY ADDRESS SITE PHONE * with AREA CODE" -e <br /> X a 3a 3 ` 1 <br /> CITY STATE ZIP CODE S of TANKS <br /> }� Ar• p�TQ� '-)A-z, Q at SITE `1 <br /> P J <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> k! L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE S WITH AREA CODE <br /> N ` 1 <br /> T CITY STATE ZIP CODE TYPE of AP <br /> jlos installation etc.) <br /> x` TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A XXXX XXXX f <br /> z C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX S <br /> t <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> X Tanks = 1986 1987 1988 1989 1990 1991 1992 1994 1995 1 <br /> F (multiply * by fee for <br /> A each year applicable) XXXX XXXX <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX $ - <br /> L J <br /> I STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25287 <br /> T <br /> Y N Tanks,3 x 556.00 1988 through 1990 1991 through 1996 1v <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. N(s) <br /> L <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) R TANK(s)-, _ X $234.00 = S g <br /> S <br /> U TEMPORARY CLOSURE (Plan Review i Inspections) TANK I.D. #(a) 7 53 <br /> R <br /> P- <br /> EI TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) NTANK(s) X 5234.00 = S <br /> P INSTALLATION PLAN CHECK (Plan Review i Construction Inspections) TANK I.D. Na) <br /> L <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S62y.00 minimum <br /> DD7SS <br /> R REPAIR FEE (Workp(an Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) S TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) 5234.00 minimum % <br /> R <br /> PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE it 578.00/hr S <br /> r <br /> ,1, - 0-C ' ve e n !�,-{ d f MAL DUE <br /> I*OF � ONLY f <br /> :<< <br /> .. MORE. <br /> SWEEPS N COMPUTER 10 LOC CODE 01ST CODE AMOUNT RECEIVECHECK /CASH RECEIVED BY DATE RECEIVED <br /> 'G <br /> N <br /> EN 23 032 (REVISED 6-21-93) Page 11 <br />