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SAN JOAQUIN COUNTv 'UBLIC HEALTH SERVICES - ENVIRONMENTAL HEALT 'IVSION <br /> UNDER*,,,ND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T FMl(�TOWN & COUNTRY HAY & FEED SMR. JACK FRANCISCO <br /> E tADD%SIN STREET +YF §PTI J{yl;�i�AREA CODE <br /> J�l1l.KT0N TATE ZIP # of TANKS <br /> A �A yS l� at SITE ESTIMATED THREE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L P12. .JACK FRANCISCO MR, .JACK FRANCISCO <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N 8341 ORANGE COURT 1 (703) 780 537) <br /> T C TY STATE ZIP CODE TYPE of APPLICATION REMOVAL <br /> 'ALEXANDRIA VA 2230y (closure, Installation, etc.) <br /> TOTAL <br /> 7986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A f <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XX)0( $ <br /> 1 <br /> V TANK FEE = 850.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply if byby fee for <br /> A each year applicable) f <br /> I TANK PENALTY FEES ASSESSED XKXX XXXX f <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 through 19901991 through 1996 <br /> (Enter amount and year) <br /> f J <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) 5q/6,4 / <br /> 0CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = f 702.00 6777 <br /> S $ 7 <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minima /FACILITY) = $234.00 minimum f <br /> ? INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum f <br /> R REPAIR FEE (workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = 5234.00 minimum f <br /> R <br /> ( PIPING REPAIR FEE = $78.00/hour (3 hours miniffLWFACILITY) = $234.00 mini mm $ <br /> MTRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 478.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE _ $78.00/hr S <br /> TOTAL DUE S oU <br /> FOR OFFICE USE ONLY <br /> � SRieEb"S4'a� r °T L�f dd `S I fi I° ffew1mg—w to QSowxn"'" <br /> a S a <br /> .��..�s��r....�..�a..�..........w...�r..�.....�r�..r,�........................��..........�.ws,...r....:::.:7i:�..�......r <br /> rsasro�.osa�rrrisrrr�orssrsrnswar,wsAwAwsswrr..wMsr.rrrrrrw xr.aas�wa�raw zs nr awe a.w axsnwir#AwsarY r>.w�rw�.wsyso <br /> EN 23 032 (REVISED 3-1-93) Paoe 11 <br />