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SAN JOADUIN CQINTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> UN OUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> STY SITE NAME FACILITY CONTNAME <br /> 1 FACILI0o TNuaul �-Elevao Bill A 'T a� H <br /> T <br /> E FACILITY ADDRESS n �� p, SITE PHONE # with AREA CODE <br /> & '{ t�� S. 4j}"G Iwo T(� 1� NoT Fluhlt.ftA022--<i <br /> A [IT �� STATE21P CODE # of TANKS <br /> -TAT V' at SITE 3 <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I <br /> C MAILING ADD&ESS APPLICANT PHONE # WITH AREA CODE <br /> N <br /> T CITY STATZIP CODE TYPE of APP °T1.^. 9— <br /> �✓ZCJ�MI:�(.� (� L� ..(Closure, 'on .) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 �(✓G L G <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A xxxx xXXX XXXX xXXX xXXX E xxxxxxxXxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If ApplicabLe) XXXX XXXX xxxx XXXX xXXX E XXXxxxxxxxxxX <br /> I <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = .3 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX xXXX xxxx XXXX XXXX $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX xxxx XXXX xxxx $ <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every S years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks :.> x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 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) $234.00 mini mum 5 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum E <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 minimum/TANK) # TANK(s) X 5234.00 = $ <br /> A <br /> 1 TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum E <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 8234.00 minimum $ <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 5 <br /> I <br /> E <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr 5 <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY _ <br /> ....:__.._.... .... ._.....i........................._............._.P._...... ...._. ................. ............_._._..... ._...__._._... ............................_.____._._...................._._._...:. <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED e <br /> E ` <br /> ii..... ....................................................._......._._.....__......:::i!isa:::"::_::::.-:::::::.-:::ii:::::_a:i![:. ::::::___::-:-:-:. T.-..___.—......—::-:::-.-:--::..-. _Mt;s_-°':=-:: <br /> ...... ..........._ am.- <br /> ........... ..._..... .._.__....................:.. __- <br /> ................__............................................__....._..._::::::::::::::::::::::::::.:.::__... .::::::._:...._:.s:::ec=_iir ._._. _ '�:_�iii��i:i:minu�i:L=�:-�:_:_�:: <br />