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SAN JOAQUINY PUBLIC HEALTH SERVICES - ENVIRONMENTAL TH DIVSION <br /> ARGROUND STORAGE TANK PROGRAM - FEE WORKSHEPW <br /> S FACILITY SITE NAME /� �/ <br /> I /v- /J l�(.q e S l<¢ FACILITY CONTACT NAME <br /> T - <br /> E FACILITY ADDRESS <br /> SITE PHONE # with AREA CODE <br /> CITY <br /> A STATE ZIP CODE At of TANKS <br /> S -,� c./c <br /> P n � yS Zc, / at SITE o-L <br /> P APPLICANT/BILLING NAME <br /> LAPPLICANT CONTACT NAME <br /> I Phi <br /> C MAILING ADDRESS <br /> AP• 13o X 7 3 Y S APPLICANT PHONE # WITH AREA CODE <br /> N <br /> T CITY �YOJ�nH STATE ZIP CODE TYPE of APPLICATI0 ac- -L(, <br /> (Closure, Instal lat'on, etc.) a <br /> TOTAL <br /> A ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 1986 1987 1988 1989 1990 <br /> D /(gyp y0 c7 $ SDa <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx X%xx 1.�' <br /> I /UC) /coo /C7 $ 300 <br /> E <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> # Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # -by fee for <br /> A each year applicable) DO2 Z <br /> C /ego /C7 ioo Ion 324o <br /> 1 TANK PENALTY FEES ASSESSED XXxX Xxx% <br /> L <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks_ x 156.00 1986 through 1990 <br /> (Enter amou1991 through 1996 <br /> nt and year) <br /> //a (to-,W w; C/-su tPiG„-) 2 // a <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) <br /> L TANK I.D. #(s) <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 <br /> S = q <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R TANK I.D. #(s) <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = q <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 minimum/FACILITY) = 5624.00 minimum <br /> S <br /> R REPAIR FEE (Workp(an Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = q <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum <br /> R g <br /> PIPING REPAIR FEE = 178.00/hour (3 hours minimm/FACILITY) = 2234.00 minimum <br /> E <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED REEEVALUATIEON = 8.00/hrISC CONSULTATION FEE = E78.00/hr SAMPLING INSPEC8.00/hr <br /> f <br /> FOR OFFICE USE ONLY TOTAL DUE <br /> .. ...:..:u.::.........:r.....:.... .:::::::.:_u,:.:-:::::::r:::::::::::�:rmrm:::,re.;;m: <br /> # W <br /> PS COMPUTER # LOC CODE DISI CODE AMNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED !a <br /> ,k IL I ROTOR/S o/ 3�3 q i! <br /> ar <br /> ,(fq� . ....._!!::::::_:_!:::r::::::_:a -::::::.:::t �:::r:::r:ren::;!sa!:!rr:r:::::::::traa:;iiiHi�� <br /> EH 23 032 (REVISED 11-1-92) <br />