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SAM JOAQUIN COUNT BLIC HEALTH SERVICES - ENVIRONMENTAL NEALT VSION <br /> IRDERbm= STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME \\ _ FACILITY CONTACT NAME <br /> 061 To(-a, S <br /> FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> s76 f: )v — c? — 7V0 <br /> CITY / // / SSTTATTE C E # of TANKS <br /> D Al <br /> at SITE / <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT MAKE <br /> L Sa �tk <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A t" 0SOX �v Y� Ica/C <br /> T CtTT STATE ZIP CODE TYPE of APPLICATION /�uiN r��� �,` <br /> Svc-��c C 9S ��� ) K( 5!y3 <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 2100.00 <br /> A 5 <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx I I S <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> At Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 11995 11996 <br /> f (multiply At byby fee for <br /> A each year applicable) I S <br /> C <br /> [ TANK PENALTY FEES ASSESSED I xxxx Xxxx S <br /> L <br /> I STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See California H 5 S Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) TANK I.D. #(s) <br /> L <br /> l I <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X 5234.00 = S <br /> S <br /> Up TEMPORARYCLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimm/TANK) # TANK(s)_ X 5234.00 S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = $624.00 mini mm S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ X 5234.00 = S <br /> I TANK RETROFIT REPAIR FEE = 278.00/hour (3 hours min./FACILITY) = 5234.00 mini mm S <br /> R <br /> PIPING REPAIR FEE = 278.00/hour (3 hours minimAn/FACILITY) = 5234.00 mini mm S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr Ipap iA� .4 I;�" S -? - <br /> S <br /> C CONSULTATION FEE = 278.00/hr I SAMPLING INSPECTION FEE - 578.00/hr S <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED I CHECK #/CASH RECEIVED BY I DATE RECEIVED <br /> 5 <br /> �(�- oZ C/NCTP/9 O/ 3d 3 <br /> s _ <br /> EH 23 032 (REVISED 11-1-92) �.. Page 11 <br />