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SAN JOAQUIN A PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WOR <br /> ENVIRONMENTAL HE�DIVSION <br /> S FACILITY SIT NA EE WORKSHEET <br /> 1 FACILITY CONTACT NAME <br /> E FACILITY DORESS <br /> /•_Ur� SITE PHONE # with AREA CODE <br /> & LI 7Y Zo9- 9s/- /l03 <br /> P a[ SITE <br /> A STATE ZIP CODE <br /> � Of TANKS / <br /> P APPLICANT/BILLING NAME /U LGII// <br /> L APPLICANT CONTACT NAME <br /> I <br /> C MAILING ADDRESS <br /> A APPLICANT PHONE # WITH AREA CODE <br /> N <br /> T CITY <br /> STATE ZIP CODE TYPE Of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> A ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 1986 1587 1988 1989 1990 <br /> L 100 too /00 /00 /00 $ cj p D <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> 1 xxxx xxxx /pp /pQ (oa f OD <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) <br /> E $170/TANK (After January 1, 1991) <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) <br /> C XX "J ''I5b 5D 5D 5D 5D I D I�VJ1 N A f 590 <br /> I TANK PENALTY FEES ASSESSED %XXX XXX% lV 60 <br /> 41 bV <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 through 1990 <br /> (Enter amount and year) 1991 through 1996 <br /> 5(o $ <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimus/TANK) <br /> S # TANK(s)_ X $234.00 = ; <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R TANK I.D. #(s) <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours mininWFACILITY) _ $234.00 minisun <br /> f <br /> INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> PLAN CHECK FEE = $78.00/hour (8 hours minimus/FACILITY) _ $624.00 minimum <br /> S <br /> REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimm/TANK) # TANK(s) - X $234.00 = <br /> $ <br /> TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 mini mm <br /> S <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimm/FACILITY) _ $234.00 mini mm <br /> S <br /> TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br /> S <br /> ONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr <br /> f <br /> TOTAL DUE f 2 <br /> FICE USE ONLY <br /> ......................................................... ........ <br /> .xrzmars�waswe.xesxeee.»»wawwe»wrzao»ee»ioa za.x:eiG:ixwneaezme:im'sz»ux»risiw»•••••xie»:»irw�x..»xx»zeswweieeeeeiwieoeiweizwesioiY'saariis%es.•••�..•••....•�y <br /> ................................ <br /> �Ss �wxws <br /> a <br /> S a <br /> .............. ........................ .................... ........................ .................................. I.... ...................... ....... <br /> •••••zi.=..e.»e....».»...:se:zu'a::»�e:.::` ::i:x'»:ti:»z:u::»Ga:xeee.r.vo. <br /> is wra aex wrox wx wt<amar aw was wx wva as atp wx xx wra ws was wr wva an r mt xqn as xeax xn anx aex mw xrs ws my xeu xa m zrs cax na xex xwn aau fps ars sna a.n aux rx aa�was ara axx <br /> 32 (REVISED 3-1-93) Paae 11 <br />