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SAN JOAQUIN (TUN" PUBLIC HEALTH SERVICES - ENVIROW ENTAL HFA DIVISION <br /> UNO 3UND STORAGE TANK PROGRM - FEE UORKSHEET <br /> 5 FACILITy SITE NAME <br /> �� pf� �L FACILITY CONTACT NAME <br /> K.TAX R0.�ID �rAVtSN'�111 e-(' <br /> i <br /> E fACILI IT <br /> FDD RESS <br /> SITE PHONE N with AREA CODE <br /> y r W weeF �e e♦ Ua e. 209 94s 575(o9 <br /> CITCY STATE ZIP CODE N of TANKS <br /> A J-�'C>✓ti.'Z'tl'1 Gtr <br /> at SITE <br /> P <br /> L APPLICANT/BILLING NAME 'e fm� maAaj�-w"-& APPLICANT CONTACT NAME <br /> I VL CQ7'cA �y 1101^ <br /> C MAILING ADDRESS APPLICANT PHONE N WITH AREA CODE <br /> W 500 G 5`FteeT SW 91(c 3(pt 09008 <br /> T CITY` ' ,L STATE ZIP CODE TYPE of APPLICATION <br /> �tJG1S�1V1 i�tn OC 952-01 (Closure, Installation, etc.) 00�D YC_ <br /> TOTAL <br /> 1987 1988 1989 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = s10o.00 1986 1990 <br /> A loo too too too too S 500 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) X%XX XXXX 10 O loo l0 o S soo e O <br /> 1 <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> N Tanks = 1 1986 i987 19E8 19E9 11990 1991 1992 1993 1994 1995 1996 <br /> F (multiply Y by fee for <br /> C each year applicable) So So SO 50 50 no 11-10 no s 7(op°p <br /> I TANK PENALTY FEES ASSESSED XXXX xxxx SO ISO So t10 110 110 C <br /> S to o 0o <br /> 0 <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due evrry 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y N Tanks_ z 556.00 1966 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S(oot) s Z oo <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. A'(5) N <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minin.m/TANK) N TANK(s) I X 5234.00 - <br /> S <br /> U TEMPORARY CLOSURE (Plan Review d Inspections) TANK I.D. N(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours uinimm/TANK) N TANK(s)_ X 5234.00 = S nS <br /> P INSTALLATION PLAN CHECK (Plan Review 5 Construction Inspections) TANK I.D. N(s) 1' <br /> L <br /> N PLAN CHECK FEE = S78.DO/hour (8 hours minim,m/f ACILIlY) 5624.00 mini mura S <br /> TP7AWK <br /> EPAIR FEE (workplan Review 8 Construction Inspections) TREK IDN(s) <br /> LIN:N'G REPAIR FEE = 578.00/hour (3 hours minimcm/TANK) N 1ANK(s) X S234.00 Sgf <br /> ANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITT) - 1234.00 minim m S95IPING REPAIR TEE = S78.00/hour (3 hours minimiWFACILITY) $234.00 minimum S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S �S <br /> I <br /> IS <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S rv( <br /> TOTAL DUE S a15tPG OD <br /> _FDR OFFICE USE ONLY <br /> .•sr..—c__::,z::=:.—::e:m::::cx::e:::.c:e._:::::...__...._..___.._... _ .ve:x��:.,:uc:.-1EE.m.:n?T_:R.:_.n.uu:eS.-_::r v"!_S'_��_::::::_.T_�..—�.—..:.......--:rs <br /> SWEEPS :__, �— --a_H= <br /> COM,DUtER N IOC COOE DIST CODE AF13JNT RECEIVED CHECK N/CASII RECEIVED BY DATE RECEIVED R <br /> e <br /> -�-f;�=,'"__,: ..,.. n-_:n=.. -ter -= e:_. . . :r m-_-m''p.r`___� .-:*q"r.e:�E:es=T_^_-�:_� _.�r�er.=m.m•:�::es.*ra:i <br /> _z_z__.�_ _:_ .�_:__.._�_ ..__�:_c'c-�:W:eta,ms•.�•.�,.:�:..m_,�'.�n_r�:•._Ea:=:_-�u::e��'-�ytsc���u::..s <br /> EH 23 032 (REVISED 11.1-92) Page 11 <br />