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SAN JOAQUIN Cal PUBLIC HEALTH SERVICES - ENVIRONMENTAL HELI IVSION <br /> UND O)ND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> Sj rACILiTY SITE NAME - FACILITY CONTACT NAME, t <br /> I' // w -17- Ile (2liv 6-) C <br /> .e. ( t cvi �� k c✓ <br /> T� <br /> E FACILITY ADORE SS 517E PHONE # with AREA CODE <br /> x <br /> CITYc STATE ZIP CODE # of TANKS - <br /> A J'/ c /C / /' zJ L- at SITE <br /> P U ( U <br /> P APPLICANT/BILLING NAME / _ / APPLICANT CONTACT NAME <br /> I <br /> C -MAILING <br /> APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> STATE ZIP CODE APPLICATION <br /> TI CITY MJ d`5 /� 3 Closure Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> S <br /> A <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %%%% %%XX 5 <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks 1986 1987 1988 1 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) _ <br /> C <br /> i TANK PENALTY FEES ASSESSED %X%% %X%% 5 <br /> L <br /> I <br /> STATE SURCHARGE + $56.00 each TANK (Due every 5 years) See California NRS Code, Section 25287 <br /> T <br /> Y R Tanks_ x 156.00 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 + 578.00/hour (3 hours mfnimua/TANK) # TANK(s)_ X $234.00 = 5 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review R tnspecti ons) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE + 578.00/hour (3 hours minimum/TANK) - � 'd ny" 7 C2� <br /> Pj INSTALLATION PLAN CHECK (Plan Review R Construction Inspeeti8 "' f �� <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours mini!ram/FACILITY) 5624.00 minimus S <br /> RI REPAIR FEE (Workplan Review R Construction Inspections) <br /> El <br /> P TANK LINING REPAIR FEE + 578.00/hour (3 hours minimum/TANK) # TANK(s) _� % $234.00 = S <br /> A <br /> 1 TANK RETROFIT REPAIR FEE + S78.00/hour (3 hours min./FACILITY) + 5234.00 minimum % <br /> R <br /> PIPING REPAIR FEE 578.00/hour (3 hours minimAn/FACILITY) = 5234.00 minimum S <br /> M AM <br /> MSI TRANSFER FEE $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr NT 5 <br /> rU <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr N q V 0 q 1992s <br /> JOAQUIiVTgtA.I�f� s G�,OL� <br /> PUBLIC HEALTH ScRVI(-_S <br /> FOR OFFICE USE ONLY ENVIRONMENIALhr.,: ' . <br /> 1 17 21!.1niannamnanRxT='�.. 11101m0mPl ^m! '14^m!i^^ .. <br /> :f.:.�i4d-':'FxT.E1 8iN!�d!L9:'!�l3EHL'i!iii:'ik"dim!y.'F23RJ...•. <br /> Minn iti Min <br /> L4mif.9 Sd83l1 Edi iLtil:uL u .:A E!:vd_iiVE <br /> SUE EPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED :CHECK�NACASN RECEIVED BY GATE RECEIVED <br /> 3 SyauG( o / 3.0�)3 <br /> :...:......:.... <br /> : <br /> EH 73 032 (REVISED 11-1.92) // _ Page11 • <br />