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SAN JOAQUIN r TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL Hr rH DIVSICM <br /> L,.,tGROUMD STORAGE TANK PROGRAM - FEE VJCRKSHEE <br /> S <br /> FACILITY,;)TE NAME �% FACILITY CCNTACT NAM <br /> Ti /// I AU I <br /> 3 FACILITY ADDRESS - GCS SITE PHONE x with AREA=COE <br /> C a5 Q/ <br /> CITYT TE /P CGDE^ x of TANKS <br /> A7 tJ at SITE <br /> P <br /> PI APPL T/BILLING NAME �� APPLICANT CONTACT NAME <br /> L <br /> I <br /> 117 <br /> C MA{ G ADDRESS APPLICANT PHONE At WITH AREA CODE <br /> A 6 <br /> M , w D <br /> TIGN <br /> TI CITY STATE RIP CODEv TYPE of lAPPLICa!\ LTJ- a (Closure, InstalLlatLat ion, etc.) <br /> TOTAL <br /> 1986 1987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior -o January 1, 1991) = 5100.00 <br /> AXXXX KXXX �100,1/o0-il oo 53DD, <br /> G <br /> T FACILITY PENALTY FEES ASSESSED (I£ Applicable) I XXX% XXXX Cj(D0-j1 C) { <br /> S D <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> F *multks x oY fee for 1986 1987 1988 11989 11990 + 1991 11992 19933 1994 11995 1996 <br /> A� each year applicaol e) I XXXX ( XXXX Ips al 1c'0) — IC) 51� �i 0� - 5 GP]Y <br /> C. / ( 011 <br /> { TANK PENALTY FEES ASSESSED I XXX% XXXX I �d l�D /��y 1 D 16(0-5 1 (/I 5 <br /> L' v <br /> II STATE SURCHARGE = S56.JO eaen TANK (Due every 5 years) See California H 3 S Code, Section 25297 <br /> TI d Tanks x S56.J0 1988 through 1990 1991 through 1996 <br /> a (Enter amount and year) _ 5 <br /> CI PERMANENT CLOSURE (Removal ar Authorized Closure-in-Place) TANK I.J. x(s) <br /> L; <br /> 01 CLOSURE FEE = 278.70/hour 13 :lours pini mim/TANK) I iANK(s) X 5234.00 = S <br /> S' <br /> U TEMPORARY CLOSURE (Plan Review 3 Inspections, TANK :.0. x(s) <br /> x <br /> EI TEMPORARY CLOSURE FC_ = S78.30/hour (3 hours mininm/FACILITY) 5234.00 minim S <br /> P� INSTALLATION ALAN HECK (Plan Review i Construction Inspections)I TANK 1.0. x(s) <br /> L <br /> A <br /> NI PLAN CHECK FEE = S78.JO/hour (8 hours miniauNFACILITY) = S624.00 minimum S <br /> Rl REPAIR FEE (Workplan Review 3 Construction Inspections) i TANK LJ. x(s) <br /> "c <br /> P TANK LINING REPAIR --EE = 578.90/hour (3 lours min miusu'TANK) x -ANK(S) X S234.J0 S <br /> A <br /> II TANK RETROFIT REPAIR "r_. = S78.JO/hour (3 hours min./FACILITY) = S234.JO mini S <br /> R, <br /> j PIPING REPAIR FEE = S78.JO/hour (3 hours ainimm/FAC:LITY) = S234.]0 minis 15 <br /> NI TRANSFER PEE = S20.00 UNAUTHORIZED RELEASE -VALUATICN = S78.30/hr I S <br /> 1' <br /> S <br /> CI CONSULTATION FEE = S73.JO/hr SAMPLING INSPECTION :EEE = S78.00/hr S <br /> TOTAL DUE 35, L <br /> FOR DFFICE USE ONLY <br /> 3 iWEEPS x LCMPUTER -CC :."DE ]IST C" : AMOUNT RECEIVED CHECK -/CASH RECEIVED 3Y .iDATE RECEIVED = <br /> = S <br /> _. __._ ___ _ _ _ _____ <br /> =H 23 032 (REVISED 10-23-93) /Q• �/` L / �, <br /> /q DD ThLL� TC ( o <br />