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SAN JOAQUIN COjdjftUBLIC HEALTH SERVICES - ENVIRONMENTAL H IVSION <br /> ! UN /ND STORAGE TANK PROGRAM - FEE WORKSHEEM <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T _..__.VtA0 vl4qS KrxApL t o <br /> E FACILITY,.ADORESS SITE PHONE # with AREA CODE <br /> & <br /> .CITY STATE ZIP CODE # of TANKS <br /> A at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> IYposifr TAD <br /> C .MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A '2-Wo <br /> NSTATE ZIP CODE TYPE of APPLICATION <br /> T CITY,. �O CP q,< (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX $ <br /> V TANK FEE = 850.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1997) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> (multiply <br /> A eachyear applicable) <br /> r .Jw $ <br /> C <br /> 1 TANK PENALTY FEES ASSESSED XXXX XXXX $ <br /> L <br /> I STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California N & 5 Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 through 1990 1991 through 1996 59 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) X12 v <br /> L <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234. = f 9 3 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TAN s)_ X 5234 = E <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspect ions) TANK I D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I. . #(s) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimun/TA ) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACT TY) _ $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVA L INION = 878.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr S <br /> TOTAL DUE $ 3 O <br /> i <br /> 77 � 7 <br /> J <br /> Y C <br /> FOR OFFICE USE ON L 6�j/ <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK /CASH RECEIVED B DATE RECEIVED }; <br /> ��S 11 <br /> • rr„ <br /> la <br /> c! .. .................. .. ... .... ... ./..y...._.r :.rn::.u:n:nmm,:::.e::n n:nnnn:m.•n:, n:usam. m::nnn.::v...n::,:: ,.9nn m!i! ....... <br /> ........................ M.M........ .. ..._ ....... ,mn,mu UMMIjim_:.:....:..m.T3:_...._..:...0 m: .i..,..... u.i................... .:..�...... .:c:.r .:n..n...,..::.._ <br /> ............................. ................................................. ...:::....:..._........_...:..._..v,...:..r:,::::::!_. :::::::_:::::...:_...,:. .:ic_:=,::::::1:::_:::!:lii!::;i!i!ii.:e:iii!!i,:::::::,::::::::::::::.::u::e:::::,:::::::,::::u::!!;!!!i!!r..r...........:r...i. <br /> EH 23 032 (REVISED 11-1-92) / 5 (] Page 11 <br />