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4—eS-1997 3:06PM FROM P. I <br /> SAN JOAQUIN COUNTY PUBLIC HRALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE 'TANK PROGRAM -FEE WORKSHEET <br /> S FACILITY S17E NAME FACILITY CONTACT NAME <br /> T L I N pA <br /> E FACILITY ADDRESS SITE PHONE N with AREA CODE <br /> A 1 53 6E II TH ST 0209) 32 — 1S <br /> A CITYCAE 21P COOS at SITEof NK$ <br /> P T <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> SI }RIMS NIAIrJNRNCE IT�G r�OSE StlAVv <br /> AMAILING ADDRESS APPLICANT.PHONE N WITH REA CODE <br /> N Po gUu 3!010 ?_C29) (0(08-843(c <br /> T CITY STATE 7(P CODE TYPE of APPLICAT ON <br /> CA y53<51 (Closure, Installation, etc.) REPAIR <br /> TOTAL <br /> A TANK FEE 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> C <br /> T # Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> 1 (multiply T -fee for <br /> V each year applicable) xxxx xxxx xxxx xxxx xxxx S <br /> E <br /> TANK PENALTY FEES ASSESSED xxxx xxxx xxxx xxxx xxxx $ <br /> S <br /> 1 STATE SURCHARGE = $56.00 each TANK (Out every 5 years) See California N 8 S Code, Section 25767 <br /> T <br /> E N Tanks x $56.00 1986 through 1990 1991 through 1996 i <br /> (Enter 3413 nt and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hsurs minimum/TANK) N TANK a)_ x $234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 6 Inspections) TANK I.D. <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> LINSTALLATION PLAN CHECK (Plan Review 6 Construction Inspec tions)l TANK I.D. #(s) <br /> N PLAN CHECK FEE a 578.00/hour (8 hours minino/FACILITY) = $626.00 minimum <br /> IN REPAIR FEE (Workplan Review i Construction Inspections) TANK I.D. #(s) <br /> P' TANK LINING REPAIR FEE a $78.00/hour (3 hours minimum7TANK) N TANKW x $234.00 <br /> A $ <br /> I TANK RETROFIT REPAIR FEE a $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FBI a $78.00/hour (3 hours miniMWVFACILITY) = $234.00 minimum L.F.4Ku4T.rac Z S 2.34,00 <br /> TRANSFER FEE a $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> S <br /> C CONSULTATION FEE f78.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE 2 34.0 0 <br /> F FLOE....WSE..AN17 ,..;._..... <br /> !IXQ.F:.:. a �L.... . ..,:,: . .. ...... <br /> 1tl .IGS. n ....:....:..:,... a.. 1 III L..........__...::_ .. YIIi.E .....................l.ulm uix.....d...__....._..R9YAwmmr Imp 5 u:_._........._.aunnaurmrialimri�riil_![!=_aiiT.!II..I!Im^.C! <br /> ,.,(��•I .�r � L •. . IAV .; <br /> II x I I -:a. .._. Imll _. .:u4Nalh Imnuu' :: ::.'^Illtm)Illlil ji <br /> ro il>���f # T COgiPiT k ■N P tdc toD@ Drsr toi e�u(Y aEc l d �r( cr #Ira ror �RLCEiVED 8Y DATI? REC IVB <br /> 10 51 1m F y •1' IIXmYYIR ; r II 1111 tl 1^N IIeYPmIff <br /> i^'V1 - 'RPI maR11111X,! ll i 51 n! <br /> °P nmh_... M luu ul f4llu,.,., .__ V7 MmWIw6.11.. <br /> L ...i°...... .':9!.1'kmm IIIIi ' `R III 1111 . '.. F X _.T....a.11lm ' -"'_'; .:F.....,...:.IIImRlw4l.!'u'a.. •••••:: <br /> EH 23 046 (Revised 7/10/96) Page 11 <br />