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SAN JOAQUIN C 'Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL F 'H DIVSION <br /> U%.eRGROJND STORAGE TANK PROGRAM - FEE WORKSHEEI-W <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> 1 511- } Pwo siLas{ <br /> T <br /> E FACILITY ADDRESS <br /> SITE PHONE 1# with AREA CODE <br /> a 3� P/1�57 Gf1 fiC� �of1� <br /> CITY nom/ SI Z�57 # of TANKS <br /> A �iQ��,n i� (/ C at SITE <br /> P ���'1 <br /> P APPLICANT/BILLING NA/ME IAP LICA <br /> NT CONTA''C//�T_, HANE <br /> L Ciyt(iO /l /G/qA fi<Tf'j'IlGZbA/ <br /> C MAILING ADD APPLICANT PHONE # WITH AREA CODE <br /> pp ,,, <br /> N r"G��� <br /> T CITY ST TE ZIP CODE TYPE of APPLICATION <br /> eA 4S3s� (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A E <br /> C <br /> 7 FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX E <br /> I <br /> Y TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1 1989 1 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) I L <br /> 5 <br /> C <br /> I TANK PENALTY FEES ASSESSED XXX% XXXX S <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H S 5 Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S ^q <br /> dz�- <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) CO213K <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_/ X 5234.00 = E Zj (� J <br /> S- -73� <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/TANK) # TANK(s)_ X $234.00 = S <br /> P INSTALLATION PLAN CHECK (Plan Review S Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 mini mm S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimxm/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr E <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr S <br /> TOTAL DUE S 23C�,oD <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED = <br /> 5 = <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />