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SAN J0AQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEA TH DIVISION <br /> UP" 'IOUMD STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONI T NAME <br /> ILO LO <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & 790 W. He-,x / <br /> CITY J STATE ZIP CODE�` # of TANKS <br /> A OP L� G�jO at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> Ly L "Tbc i4i.4-cou n <br /> I <br /> C MAILING ADORE SS APPLICANT PHONE # WITH AREA CODE <br /> As d Rd d._ X65- 7 69 <br /> M STATE ZIP CODE TYPE of APPLICATION rA�Srr�-n-7&W <br /> T CITY�^I n � a (Closure, Installation, etc.) <br /> /1 r 17 <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX <br /> 1 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E ',A <br /> # Tanks = ss_.j 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # y e for _ <br /> A each year app(icable) XXXX XXXX XXXX XXXX XXXX E 6 <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX S <br /> L <br /> I STATE SURCHARGE = 856.00 each TANK (Due every 5 years) See California H & S Lode, Section 25287 <br /> T <br /> T # Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amoun and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.D. #(s) <br /> L <br /> O CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum E <br /> P[PLAN <br /> TITEE <br /> CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> MCK $78.00/hour (8 hours m,nimm/FACILITY) = $624.00 m,nimIn S 6M Co <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours mini mm/TANK) # TANK(s) X $234.00 = E <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) = 5234.00 minimum 5 / <br /> N TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S / <br /> TOTAL DUE S�S <br /> FOR OFFICE USE ONLY <br /> _.__._................._.._........_::::::::::.— ........::::::::::.::: _::::::_ _ ::: ..................................................._,.—............:.....:__....::::__�.......,..:�. <br /> .......:_.:....::.::::::..._:_:..._:.._....._._......._::::.... _:_._. ............. :..._..::::.. <br /> ...._...:.:...:......................._........................__............................._.:_... ...H. <br /> :::._...:_::::_."""......__._:::::.::.....::::.:.:................._... .� <br /> SWEEPS # COMPUTER # LOC CODE I DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> S <br /> ......................::::::::.::::...................................... :::::_:::_.......................:::.-:::::::::::::::-�_::::::::.::::u::::::_.....::;:::;:::::..::�:' <br /> !!:::u:::=_:::_:::::::: =.:r!!!!:!!!!:::::::::_::_a;_.=._�_vie:::s::::_::::::�:::::::::::_::x�u:::u_s��::::e::::::::�:!!!u!::!::_:::u::;::::..._....... _...... ............ ........_.. ............. <br /> LI <br />