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• SAN JOAQUIN 'ITT PUBLIC HEALTH SERVICES - ENVIRCNKELTAL Y TH DIVSION <br /> IyERGRQAD STORAGE TANK PROGRAM - FEE WORXSHEDv wf <br /> S 5CIL ITY SITE yyuu++E FACILITY CONTA NAME <br /> i dN LdN AAP(o'�L�U,u�S VXUAM i VlwSUd <br /> E FACILITY ADDRESS ' ` SIE PH E # with AREA CODE <br /> a 2$SI r NAll� ► 09 �3�l-030 <br /> CIT '` NEI ZIP CODE/ # of TANKS <br /> A 101 y/` 9S L(.[C) at SITE 2 <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT �ry TACT NAXE <br /> SEA4C0 't:Z64 f?I,4AAImoxf <br /> MAILING 121� Da l 7 S)r P -�K,f3 <br /> N 0 WITH AREA cooE <br /> T CITYM5 ATE 2G[p_CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) ILE�D7/J <br /> TOTAL <br /> 1986 1987 1968 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) a $100.00 <br /> A S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) )OW XXXX S <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 3170/TANK (After January 1, 1991) <br /> E <br /> Tanks = 1986 1987 1988 1989 1 1990 1991 1992 1993 1994 1995 1 1996 <br /> F (multiply # by fee for <br /> A each year applicable) S <br /> C <br /> I TANK PENALTY FEES ASSESSED %XKX %XXX 4-- 3 <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y '. Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> Y1� d <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) ��t <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours mini mm/TANK) # TANK(s)y 'X $234.00 = I S <br /> S <br /> U TEMPCRARY CLOSURE (Plan Review 8 Inspections) TANK [.0. #(S) <br /> R <br /> EI TEMPCRARY CLOSURE FEE = 578.00/hour (3 hours minimua/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 /> — <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours miniaLWTANK) # TANK(s) _ x $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) - 5234.00 mini mm S <br /> R <br /> PIPING REPAIR FEE 578.00/hour (3 hours mininaaNFACILITY) = 5234.00 minimus S <br /> M TRANSFER FEE 520.00 UNAUTHORIZED RELEASE EVALUATION - 578.00/hr S <br /> I <br /> Sl <br /> - 378.00/hr S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FE_E <br /> TOTAL DUE S <br /> .< OFFICE USE ONLY <br /> 3 <br /> SLEEPS # I COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK Al/CASH RECEIVED BY DATE RECEIVED <br /> S <br /> EN 23 032 (REVISED 11-1-92) Page 11 <br />