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06/09/2000 13:40 209599424a FLYING J <br />' e r SAN JOACUIN LWY PUBLIC HEALTH SERVICES - ENVIRONMENTAL NO DIVIS3DU <br />9NDERGROUNO STORAGE TANK PROGRAM - FEE UORKSHEET <br />S FACILITY Si TE NAME FACILITY CONTACT NAME <br />T - - <br />E FACILITY ADDRESS <br />ZR � 67 � C <br />CITY <br />A ( <br />P <br />P APPLICANT/BILLING NAME <br />(d <br />L <br />I <br />C MAILING ADDRESS <br />N /5 <br />T) CITY '*', <br />�-` t SITE PHONE # with AREA CODE <br />Jolt Ad r �"„'T .fit P 44l" <br />STATE ZIP CODE # of TANKS <br />at SITE <br />APPLICANT CONTACT NAM ¢r� <br />APPLICANT PHONE # WITH AREA CODE <br />a e �- T► Pelf 57r 4-j tt / <br />STATE ZIP CODE TYPE of APPLICATION <br />ell - <br />(Closure, Installation, ett.)Xpa <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 $ xxxx >� ,, <br />C - <br />T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx xxxx xxxx xxxx r« h <br />V TANK FEE = $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /># Tanks = 1986 1987 1988 1989 1940 1991 1992 1993 1994 1995 71996 <br />F (multiply # by fee for <br />A each year applicable) xxxx xxxx xxxx xxxx xxxx <br />I TANK PENALTY FEES ASSESSED xxxx xxxx xxxx xxxx xxxx k ` <br />L <br />I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25257 <br />Y # Tanks_ x $56.00 1988 through 1990 1991 through 1996 <br />(Enter amount and year) <br />$ <br />C <br />L <br />0 <br />S <br />U <br />R <br />E <br />PERMANENT CLOSURE (Removal or Authorized Closure-in•Place) <br />TANK I.D. #(s),_ _ <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s)— x $234.00 = S <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(S) <br />TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimumlFACILITY) <br />$234.00 minimum S <br />PINSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE - $78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br />R REPAIR FEE (workplan Review & Construction Inspections) TANK I.D. #(s) <br />9 <br />P TANK LINING REPAIR FEE a $78.00/hour (3 hours minimum/YANK) # TANK(S) # $234.0D <br />A _ <br />I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) $234.00 minirwm <br />R <br />PIPING REPAIR FEE - 576.00/hour (3 hours minimum/FACILITY) $234.00 mini <br />M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br />I <br />$ <br />C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br />IT,-If.IT,-If <br />.TWi7jE: <br />FOR OFFICE $ISE ONLY ___ .. iS8{n eco 3 =:gi!!1llLiq!q£g3g11qlqqi! i IEigf <br />HIM !E—^i!!! ......E E wE!EE g l!II!lttttEE3!lIi3EiEiif!iiiEit!SSS;:S :; :'€ <br />:� ��E� a�igiEgiq:tglEqtq3Gqtqieiqqltt{{���gg��IIiii �n _ __. .—.:! Ge �; s:a: is u,iE6f9i ' , i, ifglggkqimllqlE i3plu!uu fuu 5 !!1 .-:t:is!:::s„=istslslu:tti6st3311t11t .!......... <br />iE?rc`ruo'�i ia,inigiugmi�7iiililNIFIEI{{iltttEimggEltq'f&.........:ic"""•"�,ricw' <br />p SWEEPS # C�iPUTER # LOC CODE DIST CID E AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br />S <br />_ .:::::::............._............. . l ecd!::;-:::a::s:::.................. <br />............... ....._........._.._ ....._._ I!E ���::sw m•.•::r�:;�:{a;gi6Eq Il ; �:::�_:--.:�..� .•::�::a....�::.:.W.: _........,s:::�,..n.tt.gEtmnumu I I <br />.................._....__......____....:c,rikHfilii{Id311Ulgl) I .... - .... <br />►Ei 111dlligiigW7n!61rr-,•Ei!S�—;,.....�;._:eE:�:ilmaNll NHg13iNlE'iE��:::�..:�:� _......m IlEiqIAL'�!..._.....,...!'.!'.BQ!!...!!'!9'�w:�„_,_�!::cc—;!-�::::_•;......::"•S•:scia,ouimninmmui ttiig3gltlusfltl3!!!!dpdEi'.i3iiiilES:EE::E3 <br />�f A#4 0 <br />