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SAN JOAQUIN COUNT PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALT IVSION <br /> LIND W STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T l S ' o T� ToN <br /> E FACILITY DRESSRolSITE PHONE # with AREA CODE <br /> •f7GOf <br /> d <br /> A CITY �� ^ fT TE ZIP CODE # of TANKS <br /> 'FdJ• ?j at SITE <br /> P <br /> P APPLICANT BILLING NAME APPLICANT CONTACTWE <br /> � . 'r S c- �✓I e� <br /> C MAILING ADDRESS APPLICANT PHONE # WITH'AREA CODE <br /> If <br /> a2 Fp CSO` 7 <br /> a - <br /> T CITY ,^ 3Q. STATE ZIP CODE T APPLICATION—T�'/NT C,60 <br /> 1 3 C(osur Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A XXXX XXXX f <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX f <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> 41 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1 1995 1996 <br /> F (multiply # by fee for <br /> A each year app(icable) XXXX XXXX 9 <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX I XXXX f <br /> L <br /> I STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25267 <br /> T <br /> Y # Tanks A $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) aa6 —0 3 0'/6:5,04, <br /> L <br /> 0 CLOSURE FEE - 578.00/hour (3 hours mini mum/TANK) # TANK(s) X (234.00 = f 0' <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/TANK) # TANK(s) X 5234.00 = f <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE _ !78.00/hour (8 hours minimm/FACILITY) _ &624.00 mini mum $ <br /> R REPAIR FEE (workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE - f78.00/hour (3 hours minimRi/TANK) # TANK(s) x 5234.00 = f <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) : f234.00 minim S <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 mini mm S <br /> N TRANSFER FEE _ &20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = 978.00/hr f <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> ...... ...._..................:.....:..m! ....___._............_.........__................_.........................,.._.._.._.__.:.:_..:.:.._. ._...;...._.._.......__..._.................................. _.._....._.............._.....___ <br /> ......................_....._._._.... . a <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> = 013 <br /> 1 <br /> St <br /> s ' <br /> Ltd - <br /> 7 l0 5 <br /> � 7.. ..:.... Dm <br /> EH 23 032 (REVISED 6-21-93) p)i Page 11 <br />