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0 0 <br /> SAN JOACUIM COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DiVS10N <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE LGRKSHEET <br /> FACILITY SITE NAPE <br /> 1114la- /j er /J zJas FAC4ITY CONTACT NAME <br /> E FACILITY ADDRESS <br /> & 60/ e, ice!y/M/= v! SITE PHONE #wjth AREA CODE <br /> G r/Y/J6 <br /> A <br /> CITY SST TE ZIP CODE # of TANKS <br /> � zo/v C� <br /> P at SITE <br /> P APPLICANT/BILLING NAME <br /> L �/�M G� APPLICANT CONTAC'TJ+ANE <br /> I 7 h �` ri.�-Kt /W/G-r <br /> C MAILING ADDRESS TN <br /> N APPLICANT N�H�SA� E <br /> T CITY SLATZIP COOE TYPE of APPLICATION <br /> /�60�S7o <br /> E (Closure, Installation, etc.) <br /> TOTAL <br /> A ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1986 1987 1988 1989 1990 <br /> C 5 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I %XXX xxxx S <br /> V1 TANK FEE = s50.00/TANK (Prior to January 1,1991) <br /> E 1986 1987 1988 1989 1995170/TANK (After January 1, 1991) <br /> Tanks = 01991 1992 <br /> F (multiply # by fee for 1993 1994 1995 1996 <br /> A each year applicable) <br /> C s <br /> I TANK PENALTY FEES ASSESSED xxxx XXXX <br /> L 5 <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) <br /> T See California H 8 5 Cade, Section 25287 <br /> Y # ranks x $56.00 1986 through 1990 <br /> (Enter amount and year) 1991 through 1996 <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized C(osure-in-Place) TANK .D. #(s) Lam" <br /> L r r <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minim (TANK) <br /> S # TANK(s)�1 X 5234.00 = 5 <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) '�O <br /> R T K I.D. #(s) <br /> r: TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimua/TANK) # TANK <br /> X $234.00 - S <br /> P [N S7ALLATION PLAN CHECK (Plan Review & Construction tnspec Cions) TANK L0. #(s) <br /> L <br /> A <br /> N DLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) <br /> = 5624.00 minimus S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) <br /> ETANK I.D. #(s) <br /> P TANK LINING REPAIR FEE = 518.00/hour (3 hours minimus/TANK) <br /> A # TANK(s) X $234.00 = S 1 <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br /> $234.00 minimus <br /> R S <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimua/FACILITY) = SZ34.00 minimm <br /> S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br /> I 5 <br /> S <br /> C CONSULTATION FEE = 578.001hr SAMPLING INSPECTION FEE <br /> = 578.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> y SWEEPS # COMPUTER # LOC CODE DIS <br /> E AMOUNT RECEIVED HEC #/CASH R ED BY DATE RECEIVED <br /> - <br /> 1 <br /> S <br /> 96 <br />