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SAN JOAQUIN C Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL H. H DIVSION <br /> UMI(GROUND STORAGE TANK PROGRAM - FEE WORKSHE~ <br /> S FACILITY SITE NAME FACILITY CONTACT N E .—� <br /> 1 _ <br /> I <br /> E FACILITY ADDRESS SITE PHONE with AREA CODE _ <br /> a Sao � >- 4S/-- z/6 <br /> CITY STATE ZIP CODE # of TANKS <br /> A C_lAt f at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I C✓ C O� <br /> I <br /> C ING A APPLICANTONE # WITH AREA CODE <br /> M — SS sz�8 zoo— PHONE <br /> CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 T1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 _ <br /> A xxxx xxxxS <br /> C <br /> I FACILITY PENALTY FEES ASSESSED (If Applicabte) xxxx xxxx ; <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 9 Tanks = 1986 1987 1988 1989 1990 1991 7992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) xxxx xxxx S <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx XXXXS <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 x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> 1 = <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) X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review a Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - S78.00/hour (3 hours minimin/FACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review a Construction Inspections) TANK I.D. a(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - S78.00/hour (8 hours mininAWFACILITY) = $624.00 minimum 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 minimum/TANK) # TANK(s) X 5234.00 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE =-S78.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> e <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> --:-nu—Ne.-:—:::.�rnmn_. .... ...........a—..—: ::=:n.-:=__,____ ...._..._.. <br /> '^m-n^'^ ...:::::::_:..__._......................... ..,,__;__:......._....... ..C.:"':-mZ:::c.... <br /> :..._...c__...__.._._....__._......_.._.....__.._._._.,_...._......_....... <br /> .. .. ... : !!9a11P!m6Q50.Y1'J1! <br /> _:..v.E�tw�Ldd9LL:o9Wi9n911Ei:viff�v6v:..W <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE I AMOUNT RECEIVED I CHECK #/CASH RECEIVED BY DATE RECEIVED ... i <br /> a <br /> S <br /> ._.. ..-..... . ... . ... ...... . . m':_:....._.:--'=v-!_:-v:.u[!mn,::.:.. a!!=:!v::!!!!!!!-!!-!i!!!!!!!!!ii!:!!!-!!!!!!v!vv!!!!!!!!:-!!.'—m=__::_::...::ivy. ._.::_:::::::::.._:.::. :::'::: ::�_= <br /> ..:. _................................................................... .. :-..._.:....: <br /> .. .:::::.::::.......-_....::..:.. :::::::::::-:.... .:..,::::::-:::::::::.r,-:i:v!:: !!vev;-_-::�::............... :::::::-!v!:iiiiii!v!!a'.4-,scv!i!4�_'_=!:,,-,.::-:::::-:.:ii!:v!r-......._.._:::::.-.-:.__:::::v:.:...... ___ <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />