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,* . <br /> SAN JOAQUIN T PUBLIC HEALTH SERVICES - ENVIRONMENTAL H "TH DIVISION <br /> UN OUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I A� I <br /> T <br /> E FACILITY ADDRESS SIT PHONE # with AREA CODE <br /> & o �N c�L,� �p 2D 4-4 -moi f <br /> CITY t 6 El ZIP COD/E, # of TANKS G <br /> A �Dc �� /� !/�4,�/(�� at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> Li l( � t�J o. G►LA �lDZ7� � <br /> I <br /> C MAILING ADDRESS APPLICAN PHONE # WITH AREA CODE <br /> A Zig- I� • G�4 Wl LL V? VV. <br /> N <br /> T CITY `�LV4–t ^ STPTE Z1;gc:� TYPE of APPLICATION <br /> G�I/1Jgl (Closur nstallation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX <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 (,I1V 02153 <br /> 23 <br /> F (muttiply # by fee for00 <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX $ lQ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ <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—1— $56.00 1988 through 1990 1991 through 1996 e <br /> (Enter amount and year) cp <br /> $ r <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <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 $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A 2 �� <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr $ <br /> TOTAL DUE $ of <br /> FOR OFFICE USE ONLY <br /> ..........................................................._..........._................................................................................ <br /> ............................................... <br /> ............................................................_ ...................................._.........................._..._...................................................................................................._......._.........::: <br /> SWEEPS # COMPUTER # LOC CODE I DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> ::::::::::::¢::::s:st[::::::sasaa:s:: a::::a::::::s:::::::¢::¢::_s:::::::::::::::_a::::::::::::::::::::::::::-:::=::::::::::::::___:::::::: :::::::::::::::::::::: ::::::::_::: : ::::::::::::::::::: ::::::::::::....... <br /> ........... <br /> ...._..._........... <br /> ................................................. <br /> • 9 • <br />