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SAN JOAQUIN � PUBLIC HEALTH SERVICES - ENVIR01a1E)ITAL DIVSICM <br /> UM0rgGRaAD STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME _ FACILITY CONTACT NAME <br /> I Se <br /> T <br /> E FACILITY ADDRESS r-+� SITE PHONE X with AREA CODE <br /> L A J <br /> L <br /> CITY i �jATE ZIP CODE # at TANKS <br /> A ClLw4�'AV/ G� ai SITE <br /> P <br /> P APPLICANT/BILLING NAME C�, PLl T CONTACT NAME /� , <br /> L �S CC t <br /> C MAILING ADDRESS I APPLICANT PHONE # WITH AREA CODE <br /> M act - <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> S_. G (Closure, Irotaltation, etc.) <br /> 160 — (�'1 TOTAL <br /> 1986 1987 1988 1989 1990 IOQ <br /> ANNUM FACILITY FEE (Prior to January 1, 1991) 2100.00 <br /> A XXXX XXXX /OCA X00 loo s app <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX I =(x S 3 o— <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (Atter January 1, 1991) / <br /> E <br /> 5 Tanks s 1986 9 7 1988 1989 1 1990 11991 1 1992 1993 1 1994 1 1995. 1996 �Q <br /> F (multiP(Y # by fee for _ <br /> Aeach year applicable) )0= XXXX �Y� �0 5 0 )1 701176 S ��?j n <br /> I TANK PENALTY FEES ASSESSED xnx =cc S � <br /> L <br /> I7TAURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Tx556.001988 through 1990 1991 through 1996 <br /> amount and year) <br /> T 56 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-P(ace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE - T78.00/hour (3 hours minimuNTANK) # TANK(s)_ X T234.00 = T <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)f TANK I.O. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - S78.00/hour (8 hours miniaam/FACILITY) 5624.00 minimae S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.O. #(s) <br /> E <br /> P TANK LINING REPAIR FES = 578.00/hour (3 hours minimm/TANK) # TANK(s) X 5234.00 = T <br /> A <br /> I TANK RETROFIT REPAIR FEE = T78.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION - 578.00/hr I S <br /> 5 <br /> C CONSULTATION FEE = T78.00/hr SAMPLING INSPECTION FEE = 578.00/hr T <br /> TOTAL DUE T - -/ 00 <br /> FOR OFFICE USE CNLY <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK ;*/CASH RECEIVED BY GATE RECEIVED <br /> EH 23 032 (REVISED 10-28-93) '� Page 11 �wr <br />