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SAN JOAQUIN 03MTY PUB.:! HEALTH SERVICES - ENVIRONMENTAL HEALIN 01�. ION <br /> UNDERGRCLW STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FA )LITY CONTACT NAMI 1993 <br /> Awfk'i Cr cc .tX J/lCC[L ^ �21G �i1�v i I <br /> FACILITY ADDRESS J, ITE PHONE 0 wit AREA C E J PERMIT/SERVICESILH <br /> CITY 1 STATE ZIP CODE a of TANKS <br /> Z.tj at SITE <br /> I <br /> APPLICANT/BILLING NAME _ APPLICANT CONTACT NAME <br /> f&J i. l <br /> 1(A LING AD ESS �-r� �/ APPLICANT PHONE M WITH AREA CODE <br /> CITY \ •s • zip coosnP■ e1 APPLICATION �. <br /> (Closure, Installation, <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) • $100.00 <br /> f <br /> FACILITY PENALTY FEES ASSESSED ()f Appliceble) xxxx xxxx y <br /> TANK FEE • 550.00/TANK (Prior to January 1,1991) 1170/TANK (After January 1, 1991) <br /> 9 tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> -(mea(I ��Y Sea rer _ <br /> each year applicable) S <br /> TANK PENALTY FEES ASSESSED %%%% %%%% $ <br /> STATS SURCHARGE • 156.00 each TANK (Due every 5 years) See California H 4 S Code, Section 25287 <br /> N Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> f <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Plece) TANK I.D. N(s) <br /> CLOSURE FEE • %78.00/hour (3 hours minimum/TANK) 0 TANK(s)_ X $234.00 • S <br /> TEMPORARY CLOSURE (Plan Review L Inspectl ons) TANK I.D. S(a) <br /> TEMPORARY CLOSURE FEE . $78.00/hour (3 hours mininxm/TANK) 1 TANK(s)_ X $234.00 . S <br /> INSTALLATION PLAN CHECK (Plan Review L Construction Inspections) TANK I.D. #(s) <br /> — <br /> PLAN CHECK FEE • %78.00/hour (8 hours minimm/FACILITY) • 9624.00 minimum $ I� <br /> REPAIR FEE (Workplan Review t Construction Inspections) TANK I.D. R(s) <br /> TANK LINING REPAIR FEE • S78.00/hour (3 hours mfnlaxm/TANK) • TANK(s) % 1234.00 • f <br /> TANK RETROFIT REPAIR FEE • $78.00/hour (3 hours min./FACILITY) • %234.00 minimum S <br /> PIPING REPAIR FEE • %78.00/hour (3 hours minimm/FACILITY) . $234.00 minimum S <br /> TRANSFER FEE • $20.00 UNAUTHORIZED RELEASE EVALUATION . 978.00/hr S <br /> CONSULTATION FEE $78.00/hr SAH'LING INSPECTION FEE . 978.00/hr S <br /> TOTAL DUE 1 <br /> OFFICE USE ONLY <br /> 'Mm11 ar�.3,I 8F1nFrnnnmrevm .�.:�. mm� m1m <br /> e mNNa■iNIJIeIimn m� n ar a u imu n wnamm nm1°mml <br /> SWEEPS a COMPUTER / LOC CODE DIST CODE AMIXIHT 0.ECEI VEO [NECK M/CASH RECEIVED BY DATE RECEIVED <br /> -,mmm°m'. Lem!w�u�i�mam�°n�n�e.;�io�nm�ii i�eum�vi�°i.a's�e ■ iea,�e ° i nu� ,,ff//,�,, pit- .umnJ <br /> � '■wui>�i'uii � '"' m�u/mn' nu '3 <br /> 23 032 (REVISED <br />