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Z- <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> lA1DE UID STORAGE TANK PROGRAM - FEE WORKSHEET <br /> /CILITY V1(1ECONTACT <br /> QN T NAM <br /> ( (JN -Ma / �1n� <br /> I I <br /> T <br /> E F CILI �IDRESS_ '� ITE H # v,h AREA�CODE <br /> 3 � <br /> a �, Ij, b- 7 {'9 <br /> L� <br /> CITY ,STATE ZIP CODE # of TANKS <br /> A C i I/ Mvl M et SITE <br /> P l� 1.NG NA 1 V l' i <br /> P PPLICANT/BII,LI NG NAME ��� Soc APPLICANT CONTACT NAME LA a <br /> I lL 5 <br /> C MAILING ORES I APPLICANT PHONE # WITH AREA CODE <br /> T CLTy T TE 2IP CODE YP f APPLIC ON <br /> �- � r , !2:8 El al <br /> tallatetc.) <br /> TOTAL <br /> 1966 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A xxxx xxxx s <br /> c <br /> T FACILITY PENALTY FEES ASSESSED (It Applicable) X%%% %XX% 5 <br /> 1 <br /> V TANK FEE SSO.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (mu(tiply # by fee for <br /> A each year applicable) xxxx xxxx S <br /> C <br /> 1 TANK PENALTY FEES ASSESSED XXXx xxxx s <br /> L <br /> 1 STATE SURCHARGE - S56.00 each TANK (Due every 5 years) See California H a S Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> amount(Enter at and year) 1 <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE - S78.00/hour (3 hours minimum/TANK) # TANK(s)_ % 5234.00 - t <br /> S <br /> U TEMPORARY CLOSURE (Plan Review a Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X 5234.00 = S <br /> P INSTALLATION PLAN CHECK (Plan Review a Construction Inspections) TANK I.D. #(s) 02 <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum x S <br /> R REPAIR FEE (Workplan Review a Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE - S78.00/hour (3 hours minimm/TANK) # TANK(!) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE - S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimua/FACILITY) = 5234.00 minimum S <br /> N TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> .-._....._._...._ -__. .._....__ ....-s._- .,.... ^?_4..4F.e::—:—F..::F.?!pem'!°..::_:: :'e-m_n^::::.::—vT::::?_ . ]=_:_.-."nea_°_.?_'__;,_.,,,.vv �-v in��-!.T_3 <br /> -v:e:::::v: - _ - - - _ - <br /> .._.---;• ne......_...I:!!::'u:e91'-Aii-a!iF.ii!i-eF..!eF.F_i5eni!=i-ic _i!F.:_. .......••..-._^:..:::::.. _ _ _ ____ _-_ <br /> ......._ ...._...........__v._..._........_. <br /> { SWEEPS It COMPUTER # LOC CODE I DIST CODE ANg1Ni RECEIVED CHECK #/[ASH RECEIVED BY GATE RECEIVED - <br /> 3 <br /> 5 3 <br /> ..,-:-+-a ........._.. .....—..__......m:tee.-:.-:... .-..-:-�-......':.=nom;__—:e.....m:.x+�::'^m-_ - _ _ _ _ _ _ <br /> -._._......._...__...---: vvc:r.•:-:-._-::-:::::.--::::::=v: :-._...._. •:: ._..........__.........._.......__........._.._......................_.y.._......_.............._min... _ <br /> ...:.:M.5:�>::_::_::�.- ........_.:..:.::—:::_:::-_�••�:,::..o:- ,e:,:ist:�:-i!i!=!s-i- :::�:-_.:::::::::: <br /> EH 23 032 (REVISED 6-21-93) Page 11 <br />