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sAN JOAQUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVSION <br /> OUND STORAGE TANK PROGR)1M - FEE WORKSHEE <br /> s FACILITY SITE NAME FACILITY CONTACT NAME <br /> ' �� c JW -�% �_ w' /, i ti <br /> r <br /> E FACILITY ADDRESS SITE Ehth AREA CODE <br /> d <br /> CITY STATE 21P CODE NKSA n �, ,:` ? - _PL <br /> AP APPLICANT/BILLING NAME APPLIT NAMEL INDl�A �. A <br /> IC MAILING ADDRESS APPLI # WITH AREA CODE <br /> A L' i _✓_T CITY STATE ZIP CODE PPLICATION <br /> M / n / A , installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A f <br /> C -- <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXKK XXXX $ <br /> 1 <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1 1995 1 1996 <br /> F (multiply q—by fee for <br /> A each year applicable) $ <br /> C <br /> 1TANK PENALTY FEES ASSESSED xxxx xxxx f <br /> L <br /> I STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See Celifornio H d S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 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) <br /> L <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimuan/TANK) # TANK(s)_ x 5234.00 - $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review d Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s)_ x $234.00 = 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 minimum/FACILITY) _ $624.00 minimum f <br /> R REPAIR FEE (Workplan Review d 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 = S <br /> A <br /> 1 TANK RETROFIT REPAIR FEE - $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum f <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ <br /> M TRANSFER FEE = 1120.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> 5 <br /> C CONSULTATION FEE _ 1178.00lhr SAMPLING INSPECTION fEE = 578.00/Ilr <br /> TOTAL DUE f <br /> FOR OFFICE USE ONLY <br /> . ........... .... ...... . ... ..... ....... .................... .. .......:..:.:::�:_:...;.. ..... .....,.. ... ..........:�:::. ;..,.....; ... .,..,...:i I i I Ililalaliiimi!Ilii!!iiillli!�I!I <br /> :��::::.. . :•:� r :�:::��:,�.V::I�"ii!!i!il:..uiill!'JI!!ili�il!ILIILI;Iia:i!iilll!!I!PJI!iliai!iL..:.va. <br /> 1II!I!Ilill!i!i!1!Illii!illi!�!li�liN�Ilnldlllililllmi�inli�mlah:Wii!ml!il:llaa�w!!ini:I!�II!il!li�!I!I�!iI�'!i!i!Iillminl�I�J!!!:II!!ial:all!!IL!:a!:!m!::!!:iil!I:IliCfii!fi!i!ia!ii:illlllaw...1.L.:.lullll'.1.:IL:LIL...ILA.LLI:L{.141..1.�n <br /> I: SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CIHECK #/CASII RECEIVED BY DATE RECEIVED <br /> W If $ <br /> MMIi. . ..}III.Q1 IN . ::: : :.::.:::....... ..:.::.:.:.::.......::::. ....:.....n e!:!:ani!a!liI!w!ananl!nuniian!i!Iniraa :nn!enmanninnv nmmn!nma:; ian�!nusn nun nn Imll n <br /> 1pa':n:::!:::!L!::dl!11!1,1 IIIIU:I„ :11,',1Ti li!1(((//^77NyTTr{{1!11Bppd.i.u:: d4i.ii IAIL.Lq.:d.u.J._:u..!u:Hu.l.;y::.u...;;!.::iL:�y.;.:lin!�n.al.uil .......... ....... .: ......i ,::n:. .,L.; . :::q: n1 'I minlnppm NmWmll <br /> II!r:!m.Ilia:!!!!m,,,li a!IlwlmiiiltllmlmOmliiliAliPIi�4WIniWILPIiIIIliiiiNiLl!�n!iii!IIIi!!i!C!L!Illai!:II!!!e!L:1:1I!la:ii!i!!!nA:.9M1innii4::!I!!IunlM1:w::La::u!ilalu!ia!n:::::!!isi!!!It::ll.eal.::.:.1..:.:l..:1.u.....i!ni:.:u:.u:num.i.n.11.Nnlanm!I imlmi�'Itlm!WlWmnmw <br /> EH 23 032 (REVISED 11-1-92) Page 11 • <br />