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-U2-1594 U-, :'cH19 FROTH 9522:31 P.02 <br /> SAN JOAQUIN C'OIMTY' PUYILIC REALTY SERVICES - ENVIRCNMDTTAL HEALTH DIVSIOM <br /> UWDERGROI.1UD STORW..L TANK PROGRAM FEE WORKSHEET <br /> S FACILITY ITE NAME FACILITY CONTACT NAME <br /> 1 / <br /> T <br /> E FAC IL TY ADDRESS �� ^SITE PHONE s with <br /> AREA CODE <br /> 41 <br /> d A <br /> CITY T TE F. 0 of TANKS <br /> A <br /> ➢ CnF' .J - at SITE �� <br /> ➢ APPLICANT/81 LLiNG NAME APPLICANT CON <br /> L TACT NAME <br /> I <br /> C NAILINGADDRESS APP ICANT PN E C WITH AREA CODE <br /> y R <br /> T CITYy/T/ STAT, 2IP CODEYP Of APPL1C4ilON <br /> (Closure, InsteltaElon, etc.) P� <br /> TOTAL <br /> 1986 1987 1948 1989 Figgo <br /> ANNUAL FACILITY FEE (Prior to JanuOry 1, 1991) S100,00 <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Appticab(e) )DOpt ( E <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (Atter January 1, 1991) <br /> E <br /> Y <br /> Tanks a 1986 1987 1 1983 1989 1990 1491 1992 1993 1994 1 1995 1996 <br /> F (multiply a by tee for <br /> A each year applicable) XXXX x)0ec I ,-,O I O t 3L f ---'_ <br /> C <br /> I TANK PENALTY FEES ASSESSED <br /> L l <br /> I STATE SURCHARGE - SS6.00 each TANK (Due-every 5 yenr&) Sae California H & S Cdae, SECLi"I 25287 <br /> T <br /> Y a Tank-s / x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) ._._,._ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. x(s) <br /> L <br /> 0 CLOSURE FEE - S78.00/hour (3 hours mininum/TANK) x TANK(s) X 5234.00 ; s <br /> s «� <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. 1(8) <br /> R _ <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimun/FACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Reviav & Construction lnspeorians) TANK 1.0. B(S) <br /> L - <br /> A <br /> Ni PLAN CHECK FEE - 578.00/hour (8 hours minimum/FACILITY) a $624.00 Minimum �I S <br /> R REPAIR FEE (Uorkplan Raview & Co trucrion InspectiNU) TANK I.O. $(b) <br /> E - _ <br /> P TANK LINING REPAIR FEE a S78.00/hour (3 hours minimum/TANK) R TANKW X 5234.00 <br /> A <br /> I TANK RETROFIT REPAIR FEE = $73.00/hour (3 hours min./FACILITY) - S234,00 minimum S <br /> PIPING REPAIR FEE • 578.00/hour 0 hours miniaam/FACILITY) = 5234.00 Minimum - S <br /> M TRANSFER FEE - $20.00 UNAUTHOR[7E0 RELEASE EVALUATION a 578,00/hr g <br /> Sr <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 578-00/hr 5 <br /> X215 � T rfiC U D(v � TOTAL DUE $ <br /> FOR OFFICE: USE OMLr <br /> ZLd COMPUTER x Loc CODE I 01 ST CODE AMOUNT RECEIVED CHECK X/CASH I RECEIVED 8Y I DATE RECEI <br /> e <br /> EN 23 032 (REVISED 10-28.93) <br />