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SAN JOAOUIN COU' PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE' '1 01VISIOU <br /> UNDP.`JW STORAGE TANK PROGRAM - FEE WRKSHEET , <br /> S FACILITY SITE NAME FACILITY CONTi.-. NAME <br /> f <br /> I <br /> T Ole CC S <br /> E FACILITY ADDRESS SITE PHONE X with AREA COOS <br /> 3 <br /> 15-15- Al <br /> CITY STATE LIP CODEf! of TANKS / <br /> A (�, S� ae SITE <br /> P <br /> P APPLICANT/BILLING NAME APPZL CCAS CONTACT NAME 5 <br /> L $ /�J 9lCJ.CJ.d0 <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE B WITH AREA CODE <br /> N ll 0 ST- 7S-1 r <br /> T CITY STATE ZIP CODE / TYPE of APPLICATION U z C Q� <br /> a N,� c 3� 6 (Closure, Insta(lation, etc.) <br /> s o o�y TOTAL <br /> 7986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior Co January 1, 1991) = 5100.00 <br /> A %XXX %XXX %XXX XXX% XXXX S %XXX%XX%XX%XX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> X%XX XXX% I XXXX %XXX %XXX S %XXXX%%%XXXX% <br /> I <br /> V TANK FEE 550.00/TANK (Prior to January 1,19911 5170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks _L 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1 1996 <br /> F (multiply At by fee for <br /> A each year appL icable) XX%X XXXX I %XXX XXXX XXXX / 70 / 70 <br /> X70 170 /70 /0 zv <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX X%XX XXXX %XXX x <br /> 1-707170 70 /70 S %D -� <br /> L ' <br /> I STATE SURCHARGE = S56_00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y ? Tanks L x 556.00 1980 through 1990 1991 through 1996 T.tJ V0 1 <br /> (Enter amount and year) � ,y <br /> -S-6 S <br /> C PERMANENT CLOSURE (Remova( or Authorized Ctosure-in-Place) TANK 1.0. N(s) —0 <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours mini mum/TANK) I 9 TANK(s) X 5234.00 = $ Z 3 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) I TANK I.D. !(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. N(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.001hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review 3 Construction Inspections) I TANK I.D. 0(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) k TANK(s) X 5234.00 = S <br /> A <br /> 1 TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum f <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum <br /> N TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr I % <br /> TOTAL DUE 5 Z�3 2(b <br /> FOR OFFICE USE ONLY <br /> s SWEEPS 41 1 COMPUTER 9 I LOC CODE I DIST CODE I AMOUNT RECEIVED CHECK d/CASH RECEIVED BY DATE RECEIVED y �g7� <br />