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t <br /> ' SAN JOACJIN CPUBLIC HEALTH SERVICES - ENVIRONMENTAL 11* DIVSION <br /> UND GROUND STORAGE TANK PROGRAM - FEE w0RKSHEET <br /> S FACILITY SITE NAME Fprn ITY C TACT NA <br /> AME <br /> � — S- r L <br /> fAC ITY ADDRESS SITE PHONE # with EA CODE <br /> & ZOQ—T <br /> CITY STATE ZIP CODE # of TANKS a <br /> 7 C at SITE <br /> P APPLICANT/BILLING NAME APPLICANT CONTA NAME <br /> `JCL��TbtJ n� fib. tA <br /> C M ING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N D•Zcn;w Zft'f 4 4 <br /> T CITY STATE ZIP CODE TYPE of <br /> APPLI ON <br /> (Closure, nstallat <br /> , tc.) <br /> TOTAL <br /> .. <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 8100.00 1986 1987 1968 1989 1990 f ` <br /> A xxxx xxxx ` <br /> C 8 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx E <br /> I <br /> V TANK FEE $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks 1986 1987 1988 1989 1990 1991 11992 1993 1994 1995 1996 <br /> F (multiply # -by fee for ., <br /> A each year applicable) xxxx xxxx E <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx <br /> L <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 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) _ <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L 14_ <br /> 0 CLOSURE FEE = E78.00/hour (3 hours minimum/TANK) # TANK(s) % $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 minimum/FACIIITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) f <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.001hour (8 hours minimum/FACILITY) = $624.00 minimum S 1 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 878.00/hour (3 hours minimum/TANK) # iANK(s) x $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 878.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum 8 <br /> M1 TRANSFERFEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br /> SI I _ <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr $ <br /> 0 TOTAL DUE <br /> 7 <br /> !'OR OFFICE USE ONLY ' <br /> .._.................. ........__......._...... <br /> ...._.............. ._,_.-.,,...,,..._. r <br /> ......... ............... . ..............!.a: .......... _ .......... <br /> F! i: . ::..... <br /> .:. : -' .i . .. — n <br /> .: md3!3:!!!! . <br /> a...na:...._....... ... <br /> SWEEPS # COMPUTER # LOC LODE DIST CODE AMOUNT RECEIVED CHECK 4/CASH RECEIVED BY DATE RECL!VED <br /> `e..._..—!!-„_a-:•nae:•:::...... n::..:•::::az„-:e:c.:.:..._,_...__..:::___...::::::::::_ _ <br /> a:: <br /> EH 23 032 (REVISED 10-28.93) Pinc 11 f � ' <br />