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SAN J0AQUIN 'WW���� <br /> 11PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEA DIVSION <br /> STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T -cRe�CY MUNIGPAL t��PoRT C rSON <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & 2 633 S' CRTC BL! 2.09 835- 2176 <br /> A CITE ACv STATEI ic Zsa�6 atoSITETANKS <br /> P lF 1 <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L C1� lnc c Servi Ht�t4� KlM <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A AgoSL, SOTE I 0-0 3l0- 142- <br /> M <br /> T CITY STATE ZIP CODETY PPLICATION <br /> To�K�C- CAN 4x603 Closure Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXX% XXXX S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX S <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multipLy # byfee for <br /> A each year applicable) XXXX XXXX XXXX XXXX S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX Vxx XXxx $ <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> ,_1 $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) A1t?f CL\jax"\'e— <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)t X $234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> H PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & 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 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE = 820.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> l <br /> 5 <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr $ <br /> TOTAL DUE S �3L� <br /> FOR OFFICE USE ONLY <br /> ::.— _'_.___.._._.._,,::::::_::_— ,=_:aN!e4! ' ' —:__.._..._....._..[!u�..._._.._.._.... '_'i.._:._:_ iP_'_: <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> a g = <br /> EH 23 032 (REVISED 4-6-95) <br />