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SAN JOAQUIN ALLIC HEALTH SERVICES - ENVIRONMENTAL NEA . OIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> f .TY SITE NAM FACILITY CONTACT NAME <br /> FACI4TY,'A0tRES SITE PHONE # with AREA CODE <br /> &I '-�2-7D S avi1ir— ILIL uri LV)- <br /> CITYSTATE ZIP CODE # of TANKS <br /> A c4e-7-,%j j 5_06 at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> LL <br /> I -W Wgsr a 6u G1 L Mo-s eE <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> T CITY STATE ZIP CODE TYPE of APPLICATION �ST��I <br /> (Closure, Installation, etc.) I ATIp <br /> TOTAL <br /> 1986 11987 1 1988 1989 ( 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX I XXXX I S <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 4 Tanks = 1986 1 1987 1988 1989 1990 1991 ( 1992 1993 1994 1995 ( 1996 �IUti01lt?i l7� D <br /> F (multiply # by fee for <br /> A each year applicable) <br /> C XXXX XXXX I 10 S � O <br /> Iy <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX <br /> Li <br /> 11 STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Yr <br /> s; _ x 556.00 1988 through 1990 1991 through 1996 <br /> amount and year) <br /> � S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) (01L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.06 minimum TS 3 <br /> R REPAIR FEE (workplan Review & Construction Inspections) TANK I.O. #(s) <br /> E, <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> 1 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> M TRANSFER FEE = S20.00 ( UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> `\ <br /> =` SWEEPS # I COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK */CASH RECEIVED 3Y �I DATE RECEIVED <br /> EH 23 032 (REVISED 10-28-93) <br />