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/ SAN JOAQUIN COON PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET Q� 6 <br /> S FA ILIT," SITE NAMF nn FACILITY CONTACT NAME <br /> T / V <br /> E FACILITY ADDRESS SITE HONE with AREA CODE <br /> CITY STATE ZIP CODE # of TANKS <br /> A �" C at SB TE <br /> P <br /> P APPLICANT/BILLING NAME APPLIC T CONTACT NAME <br /> S'n Mv t <br /> CMAILING ADDRESS APPLIC " HONE # WITH AREA CODE <br /> A 0, 13cq 3z Flo <br /> T CITY STATE ZIP CODE T APPLICATION <br /> CQ WCO I Jr (Closure, Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 4100.00 1986 1987 1 1988 1989 1990 <br /> A 4 <br /> C <br /> TFACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX S <br /> I <br /> V TANK FEE = 450.00/TANK (Prior to January 1,1991) 4170/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) <br /> C 4 <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX 4 <br /> L <br /> I STATE SURCHARGE = 456.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x 456.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> . 4 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) lid 3, <br /> L <br /> 0 CLOSURE FEE = 478.00/hoer (3 hours minimun/TANK) # TANK(s) X 4234.00 = 4 S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 478.00/hair (3 hours minimun/FACILITY) = 4234.00 minimun $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> N PLAN CHECK FEE = 478.00/hour (8 hours minimun/FACBLITY) = 4624.00 minim <br /> JUN 3 01993 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) EALTH DIVISION <br /> E <br /> P TANK LINING REPAIR FEE = 478.00/hour (3 hours minim/TANK) # TANK(s) X 4234.00 = 4 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 478.00/hour (3 hours min./FACILITY) = 4234.00 minimum 4 <br /> R <br /> PIPING REPAIR FEE = 478.00/hour (3 hours minimum/FACILITY) = 4234.00 minim 4 <br /> M TRANSFER FEE = 420.00 UNAUTHORIZED RELEASE EVALUATION = 478.00/hr 4 <br /> I <br /> S <br /> C CONSULTATION FEE = 478.00/hr SAMPLING INSPECTION FEE = 478.00/hr 4 <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> ........................................................ .................................................... <br /> .......................................................................... <br /> a�.a xceee�.1e9eee zoe zaMe zeazee 1ee9os100e1ee9oe 19es»9oePzee MeroeMa 1eos�ee90e 190619eroeMPe leaeroMePM9P Mea9s MaOMeroeMOO1ee90s MOP MOMO1e9e M9PaMaePlOesxe9es10eP1eeeo►1eoPMao xoeee xazee�xe►xeoe►xwxoaoo��me►zee»�aea xoe <br /> ldG M AW 3urwma WLR E t�1 "t�R E ' ZZ <br /> g <br /> i.. 4 » <br /> ................................. <br /> :KO%.O:tttt00%01Cd0e0 MOP)00000 M00 DOea%0000%00%0000%ee%OCOel000 pe060YA0%e0)PCeee lee0 Me0eO Mea%0000I0001Qee)04000 Je00 M0eeP100►%000e10007e00PP%0>%N Xaeee]Oea70eWe 109000 MOP%e►7eeeee%N 100000 Me!%WN71N 110Ma%00100e1000e►he®)00! <br /> EH 23 032 (REVISED 3-1-93) qP Paae 11 <br />