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A <br /> 1 / <br /> SAN JOAQUIN OLD PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE•DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE 61ORKSHEET <br /> S FACILITY SIT NAyE L FACILITY CONTACT NAME <br /> E FACILITY DDRESS SITE PHONE # with AREA�7� <br /> �vr� Zo9 - 951 - / 0 <br /> 8 <br /> CITY CODSTATE ZI���^ of et TA <br /> SI TENKS <br /> of <br /> A LLlr// <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1 1989 1 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 IDD IDO /DD (00 /00 $ 50 D <br /> A <br /> CXxxz XX)X /OoT,96 100 $ �U <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> 1 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 19 91) <br /> E <br /> # Tanks = 1 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee forI� (('' /'11�� (1��yy/f)) <br /> A each year app(icable) 5V 5� 5D "J� 5L/ I - 1 ru IJIA 5 59D <br /> C ! T r <br /> I TANK PENALTY FEES ASSESSED )0(XX XXXX Jb 5D 5D 1 5 <br /> L <br /> 1 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 1990 1991 through 1996 <br /> (Enter amount and year) I 5& <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TAN K(s)_ X $234.00 = 5 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum 5 <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours miniarm/FACILITY) = 5624.00 minimum $ <br /> E <br /> FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> INING REPAIR FEE = 878.00/hour (3 hours minimum/ <br /> TANq # TANK(s) X 5234.00 = 5 <br /> 5 <br /> ETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimumG REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 mini mum 5 <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr $ <br /> TOTAL DUE 5 1/ <br /> FOR OFFICE USE ONLY . _ _ __ __ _ <br /> _. .. ..................................._............................................................_................................................................................................................................__...... <br /> E�P "r'.w' i t 'AVMT am <br /> a >S <br /> %..........................1........................1.................... <br /> 1........................1.=.........._l._...1. ....1...!.!.._ .. .„ 1. .„. „ .: ; „� : „: .: „ . ; .: y .� <br /> �� Aserasxi�maa�nxa�s� � � anaasxe��A�xw�xaas�Al+st�:lmman rex aaxwssxaxaasfarssneaaanwaraxanusasxrawuuarasammaoKwsaWtwYxva <br /> EH 23 032 (REVISED 3-1-93) Paoe 11 <br />