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SAN JOAQUINTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL TH DIVSION <br /> OERGROUNO STORAGE TANK PROGRAM - FEE WORKSN:. . <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T <br /> E FACILITY ADDRESS SITE PHONE 7 with AREA CODE <br /> & qP C) z <br /> CITY STATE ZIP CODEof TANKS <br /> A �� 5 v ai SITE <br /> v /N <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> C MAILING ADDRESS APPLICANT PHONE k WITH AREA CODE <br /> A <br /> N <br /> TI CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior Co January 1, 1991) = $100.00 <br /> A XXXX xxxx XXXx S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX I XXXX XXXX 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 11988 11989 1990 1991 1992 1993 11994 1995 1996 lGfi�l a'Q' 1 1 <br /> F (multiply by fee for <br /> A each year applicable) Xxxx XXXX xXXx ! I I S D <br /> LI TANK PENALTY FEES ASSESSED XXXX I XXXX XXXX I I S <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T In <br /> Y K Tanks z 556.00 1988 through 1990 1991 through 1996 U •L I� <br /> (Enter amount and year) ,q <br /> 5 1JUI <br /> 5 <br /> CI PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. ,"(s) <br /> L <br /> 01 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) I x TANK(s) 3 X 5234.00 = S <br /> S <br /> Uj TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.O. :(s) a, �l <br /> EI TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I 8234.00 minimum 4 S 7 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. :(s) a <br /> A r� aA38D <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) _ %24.00 minimum S Zy. <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. "(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) k TANK(s) X 5234.00 = S <br /> A <br /> 11 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) v 5234.00 minimum 5 <br /> M TRANSFER FEE = $20.00 I I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> 1 <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr I S <br /> i <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> :......._..._:__-.......t......:..=....:.:._,.._:__.___...-..._:.:._:_:_:__:.:._:_::.:.:..:..-._._.:.:...._:_:.:..:..:...:_:_..:_-..:-:.__:_..._.:.-...:._:.:.:..-._.:.__.:.:.:_:___:._...._:.:_:_...::.-__.:..:...:_..:..:..:..:__.:..-._........t_..o.....o._...t..___.,........._....._..._..te.............._.—..............._e.:.-...r.._n-:::m.._ ...... <br /> _ :...-.__..;._.. <br /> .- ........--:....:;i :ii[i_�_'iiii::_::iiii:::iii::: :_':_. <br /> ............. : : . ___ <br /> ... —. m _ <br /> SWEEPS ( COMPUTER LOC CODE DIST CODE I AMOUNT RECEIVED I CHECK :/CASH I RECEIVED BY DATE RECEIVED <br /> _ <br /> - S <br /> — —... . �.:.._.__........ .�Tlro.�.—__ ::.:._ <br /> EH 23 032 (REVISED 4-29-94) <br />