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SAN JOAOUIN CJ&TY PUBLIC HEALTH SERVICES , ENVIRONMENTAL HJ&H DIVSION <br />r GROUND STORAGE TANK PROGRAM - FEE NORKSHEr <br />SI FACILITY SITE NAME I FACILITY CONTACT NAME <br />TI � b M % A I SArWi Av&24 <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I <br />9 TANK(s) X 5234.00 = 5 <br />A <br />II <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= 5234.00 minimum S <br />E <br />FAC LITY ADDRESSi SITE PHONE � with AREA CODE <br />= 5234.00 minimum S <br />g <br />1 91 QST 8,K i <br />CIT, STATEZIP CODE of TANKS <br />A <br />L.Or� I I ! at SITE <br />P <br />PI <br />APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br />11 <br />_ <br />Cj <br />MAILING ADDRESS APPLICANT PHONE WITH AREA CODE <br />NI <br />12►1 Ste` -2 _ 5 <br />Ti CITY <br />STAT -_-j ZIP CODE <br />TYP_ of APPL ' <br />6 Des Tp <br />I C/'I S <br />I (Closure, hstallation etc.) <br />TOTAL <br />1986 11987 11 1988 1, 1989 1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />Al <br />XXXX I XXXX I XXXX I ( <br />Is <br />TI <br />FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX I XXXX I XXXX i <br />S <br />I <br />V+ <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 11, 1991) <br />I cI ;� Tanks3 1986 1987 1988 1989 1990 1 1991 1992 1993 1994 1995 1996 p <br />I <br />Fl (multiply 9 by fee for <br />Al each year applicagle) I XXXX I XXXX i XXXX15- <br />SSD <br />C f <br />Ij TANK PENALTY FEES ASSESSED XXXX I XXXX I XXXX I j ( I I S <br />L: <br />11 STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25297 <br />Tl <br />Yl9 Tanks x 556.00 1988 through 1990 ; 1991 through 1996 <br />(Enter amount and year) <br />C! PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) I TANK I.D. ;(s) <br />L� <br />01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I TANK(s) X 5234.00 = <br />5 <br />S' <br />Ui TEMPORARY CLOSURE (Plan Review & Inspections) I iANK I.O. =(S) <br />R; <br />E;I TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) SZ34.00 minimum 1 S I <br />we <br />P INSTALLATION PLAN CHECK (P(an Review & Construction Inspections)I TANK I.D. .(s) Ql� <br />S� <br />�tiL1. <br />L <br />Al <br />91 PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br />i <br />5 <br />RI <br />E <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.O. (s) <br />Pj <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I <br />9 TANK(s) X 5234.00 = 5 <br />A <br />II <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= 5234.00 minimum S <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />= 5234.00 minimum S <br />MI TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />S <br />C, CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr <br />TOTAL DUE <br />FOR OFFICE USE ONLY <br />_...._........_._......._._...... <br />��SWE"EPS j COMPUTER I LOC CODE i DIST CODE I AMOUNT RECEIVED CHECK /CASH I RECEIVED 3Y <br />I ( S I <br />EH 23 032 (REVISED 4-29-94) <br />DATE RECEIVED <br />lL Z_ <br />