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D s 7/7, � �CYV I� <br /> SAN JOAQUIN COU ELIC HEALTH SERVICES - ENVIRONMENTAL HEAL IVSION p <br /> UNDE OUND STORAGE TANK PROGRAM - FEE WORKSHEET Q/ F� <br /> w <br /> S FACILITY SITE NAM FACILITY CONTACT NAME <br /> T O ( 1 <br /> E FACILITY ADDRESS SITE HONE with AREA CODE <br /> & S w �a 5 3 <br /> CITY STATE ZIP CODE # of TANKS <br /> Aat SITE <br /> P tJ <br /> P APPLICANT/BILLING NAME APPLIC^K CONTACT NAME <br /> L 9A upff to <br /> I — <br /> C MAILING ADDRESS APPLIC T HONE # WITH AREA CODE <br /> A 0- l3 0 4032 S o S <br /> N <br /> T CITY STATE ZIP CODE jTjj� APPLICATION <br /> CD A'GQ � s osure, Installation, etc.) <br /> �0(� TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX S <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX S <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> . i <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) 11 2-r, <br /> L <br /> 0 CLOSURE FEE = 878.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ 3 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum JUN 3 0 X993 <br /> Ahl <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) FN�IiEiEWIA' u EALTH DIVISION <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> IR <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum S <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE S 1136. e0 <br /> FOR OFFICE USE ONLY <br /> ................................................................................................................................................................................................................................................................ <br /> :ooexwx000e xea xooea xee xrxexwxea xo0oaxoaxo0os»eawo00o-weo-xoeeaaooszoexowoxoaxaeooxoaxooazesxa»eee►zes»ee»xaxeowxaaxeeesx�escxa»eaeszesxoowxawaeoaxeswesweeosxaxeeeexaxooeaxwxooe►waxe.xeo»xesxes <br /> ° L /LL � <br /> ........................ ........................ .................... ........................ .................................. .............................. .................................... .......................................... <br /> EH 23 032 (REVISED 3-1-93) 07 r Pace 11 <br />