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SAN JOAQUIN ' YTY PUBLIC HEALTH SERVICES - ENVIRONEYTAL '.TN DIVSION <br /> —GRCU1D STORAGE TANK PROGRAM - FEE WORKS7E— <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I T(ZA( y tnjA) <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> s 2'-1 wtsr ELeuetjm sraetr 209. sus o <br /> CITY STATE ZIP CODE # of TANKS <br /> A AC ( CA 5.7 6 at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME - <br /> LITNc C,[7-11 OF TMC PAu UF2M <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N S,70 TRAc� 13L t/0' ZO— 3 — yzo <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> TkAGk CA 'F.T' (Closure, !"&W4etim , ate.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 A,CU C/1 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A S QL(lUcS <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) )000( %Xxx S <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1 1988 1989 1 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply p by fee for <br /> A each year applicable) S �l <br /> i <br /> I TANK PENALTY FEES ASSESSED %70(X %%XX 5 <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every S years) See California H 8 5 Code, Seetion 25287 <br /> ' T <br /> Y # Tanks_ f x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) ,p o <br /> Al A <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)_j_ X 5234.00 - S 3L, VO <br /> S <br /> U TEMPORARY CLOSURE (Plan Review i Inspections) TANK I.D. #(s) �- <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minima/TANK) # TANK(s)_ X 5234.00 = S �- <br /> P INSTALLATION PLAN CHECK (Plan Review 6 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A 4 <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimun/FACILITY) 5624.00 minimum S v <br /> R REPAIR FEE (workplan Review 8 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 = S �- <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> { PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> i <br /> ler- <br /> M <br /> TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr $ <br /> n I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr 5 <br /> TOTAL DUE S U(� <br /> Y <br /> FOR OFFICE USE ONLY .- <br /> SWEEPS # I COMPUTER #-I LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> S = <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />