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SAN JOAOUIN*TY PUBLIC HEALTH SERVICES - ENVIRONMENTALOTH DIVSION <br /> 1. .,ERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> r , <br /> �• 7' FACILITY SITE NAME FACILITY CONTACT NAME„�� �/�� <br /> EI FACILITY ADDRESS ��/ ',p SITE PHONE d with AREA CODE <br /> I T� /V• �!ASO/✓ (N <br /> &I <br /> CITY ��C/ � I STATEI ZIP CODE a of TANKS <br /> Al at SITE <br /> P' <br /> Ii APPLICANT/BILLING NAME _ � APPLICANT CONTACT NAME <br /> NAME * / <br /> C� MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> Al �,� Sr�e <br /> N <br /> T CITY STATE ZIP CODE TYPE of APP <br /> ve&VIV 94 (Closure, Estatiatio; _tc.) <br /> TOTAL <br /> I 1986 1987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> AI XXXX XXXX XXXXI S <br /> C <br /> TI FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX $ <br /> 1; <br /> VI TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> l Tanks = -4§-4 11986 1987 1988 11989 11990 1991 1992 1993 11994 1995 19960 <br /> S Fi (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX I I I I /70 S <br /> 1TANK PENALTY FEES ASSESSED I XXXX XXXX ( XXXX <br /> I' STATE SURCHARGE = $56.00 each TANK (Due every S years) See California H & S Code, Section 25287 <br /> d Y Tanks x $56.00 1988 through 1990 1991 through 1996 41 <br /> (Enter amount and year) <br /> C; PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. 9(s) <br /> Ay <br /> S O; CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) I T TANK(s) X 5234,00 = 5 <br /> iS <br /> S Ui TEMPORARY CLOSURE (Plan Review S Inspections) I TANK I.D. #(s) <br /> R; p <br /> I E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I $234.00 minimum $ 1 <br /> t I <br /> c <br /> P! INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. (s) <br /> L; <br /> A <br /> Ni PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum 3 � <br /> ' <br /> i Rj REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br /> S E' <br /> P! TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I TANK(s) X 5234.00 = 3 <br /> Al Z <br /> 1; TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum 5 <br /> R' ii <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> MI TRANSFER FEE = $20.00 I I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr b <br /> 1 <br /> S' I I tl <br /> Cj CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE = S78.00/hr I I S <br /> TOTAL DUE S <br /> V � <br /> FOR OFFICE USE ONLY 3 �p <br /> :ra::::tt:tttstst EStt:t:::s::::::tt:ti:;tt :EEt:E;t:ESt:t............ t: E:t: EE :s:t t:: :ts t::s:s[::::::E:tst::t[t:ttt::tt: 1::111::¢1::1:1::t::[:t;::ct stt[t E : i_ss:::s E Es::¢wt _:'as_:s: ::E:t s <br /> SWEEPS COMPUTER I ;-_ <br /> I LOC CODE I DIST CODE ( AMOUNT RECEIVED CHECK T/CASH I RECEIVED BY i DATE RECEIVED <br /> 3. <br /> $_ ..._..�...� I..._..._._....__....._._.__ <br /> ...........................................- .............::.::::::::::_::::_..........:........._..........:- ------- <br /> . .:.....,... ..,................._...._............................._:.......---:::_.................. ......::::::::: :::::::-::::.....................................-.:-:.. <br /> _....................................................................................................._.._....._.......__.._.._ -- .._...._..__.. ................................................. <br /> ........................................................ <br /> cH 23 032 (REVISED 4-29-94) • • <br />