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F/P 7ad <br />SAN JOAQUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVSION I fP 71'7 <br />n_. vrsnem CTORAGE TANK PROGRAM- FEE wORKSHEE <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />T- <br />`fn <br />SLTJ S l`�U`I3 L- .Jv <br />Oe <br />E <br />FACILITY ADOR SS <br />�,� <br />SITE PHONE X with AREA CODE <br />5�9i_ <br />s <br />,�yy,, Y !J _ 5 <br />CITY j�'rCJ' �J'v <br />/� Z1�1 <br />3EC <br />at SITENKS <br />A <br />T�� V <br />`�TE /P� b <br />CLOSURE <br />P <br />PAPPLICANT/BILLING <br />NAME <br />APP ICANT CONTACT N <br />2 Y Yl f4 <br />L <br />0 Sf.1's eJ (ZI S' r I <br />XXXK <br />C <br />NAILING ADDRESS <br />C.��- <br />3 <br />APPLICANT PHONE X((��VITN AREA CODE <br />'"I .3i' 3 <br />N <br />I <br />T <br />CIS7TA,y���/'))) <br />I "I !JQ <br />TATE ZIP CODE I TYPE of APPLICATION <br />� S 3 b (Closure, Installation, etc.) <br />I U AM <br />C <br />PERMANENT <br />CLOSURE <br />(Removal or Authorized Closure -in -Place) I <br />1986 <br />1987 <br />1988 11989 <br />11990 <br />5 <br />S <br />U <br />ANNUAL FACILITY FEE (Prior <br />to January 1, 1991) - 5100.00 <br />(P(an Review & Inspections) <br />TANK I.D. i(s) <br />R <br />E <br />TEMPORARY <br />CLOSURE <br />FEE = 578.00/hour (3 hours minimm/FACILITY) <br />5234.00 minimum <br />5 <br />XXXX <br />XXXK <br />S <br />A <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED ([f Applicable) <br />I XXXX <br />%XXX <br />S <br />V <br />TANK FEE = 550.00/TANK <br />(Prior <br />to January 1,1991) <br />5170/TANK <br />(After <br />January <br />1, 1991) <br />S Tanks = S <br />1986 <br />1987 1988 11989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />F <br />(multiply d -by fee for <br />I <br />✓ <br />A <br />each year applicable) <br />%XXX <br />XKXX <br />C <br />5 <br />LI <br />TANK PENALTY FEES ASSESSED <br />I XXXX <br />%XXX I <br />I <br />STATE SURCHARGE = 856.00 <br />each TANK <br />(Due every 5 years) <br />See California H & <br />S Code, <br />Section <br />25287 <br />T <br />Y <br />4 Tanks x 856.00 <br />1988 through 1990 <br />1991 <br />through <br />1996 <br />------ <br />---(Enter <br />(Enteramount and <br />C <br />PERMANENT <br />CLOSURE <br />(Removal or Authorized Closure -in -Place) I <br />TANK I.D. l(a) <br />L <br />O <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK)X <br />TANK(s)_ X 5234.00 = <br />5 <br />S <br />U <br />TEMPORARY <br />CLOSURE <br />(P(an Review & Inspections) <br />TANK I.D. i(s) <br />R <br />E <br />TEMPORARY <br />CLOSURE <br />FEE = 578.00/hour (3 hours minimm/FACILITY) <br />5234.00 minimum <br />5 <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D.(s) <br />L <br />A <br />N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY)= $624.00 minimum S <br />R <br />REPAIR FEE (workplan Review & Construction Inspections) TANK I.D. N(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I S TANK(s) % 8234.00 = <br />5 <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 mini mm <br />5 <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />S <br />MI <br />TRANSFER FEE = $20.00 I UNAUTHORIZED RELEASEE EVALUATION = 578.00/hr <br />S <br />I <br />I I <br />S <br />C <br />CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br />g <br />TOTAL OUE <br />S 6 7 <br />OR OFFICE USE ONLY <br />R 1 COMPUTER 7 1 LCC <br />DIST CODE I AMOUNT RECEIVED I CHECK <br />s <br />E"132(REVISED 10-28-93) ' Page 11 <br />RECEIVED BY I DATE RECEIVED <br />