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5-26-1998 1 :d8PM FP.Of I P d <br /> . Y <br /> SAN JOWIN COUNTY PUBLIC HEALTH SERVICES - ENVIRM MTAL HEALTH DIVSION <br /> UNBER(IMM STORAGE TANK PROGRAN - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> 1 <br /> E FACILITY AOORESS SITE PHONE a wi,h AREA CODE <br /> t 1 :3Uc - '7tJ <br /> CITY STATE ZIP CODE ♦ of TANKS <br /> p ,� Iat SITE -2 <br /> P APPLICANTAILLING KANE APPLICANT CONTACT NAME <br /> L E��1� Y� 1 5 5 <br /> I <br /> C NAILING ADDRESS APPL!(ANT PHONE 5 WITH AREA CODE <br /> ,"N CATH ST. 71-DM <br /> T CITY STATE ZIP COO TTPE Of APPLICATION -yY�-Tfl L ,ry7T-1 <br /> (C(esure. Installation, etc.m`n—� ruyt <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) S700.00 1956 1987 1960 1989 1490 <br /> A )DOR )DOR xW xxxx Mao 5 xxxxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) + XXXX %%X% 100fX 10(Xx %%70( i XxxxXxxx <br /> I <br /> WTANK FEE • S50.00/TANK (Prior t0 January 1, 991) SITU/TANK (After January 1, 1991) <br /> s Tanks = 1987 1968 I TM 1990 1991 I <br /> F (euttipty N by fec for T992 1993 1994 1995 7996 1997 <br /> A each Year applicable) xxxx xxxx xxxx )0= xxxx I I 2 <br /> C <br /> 11 TANK PENALTY FEES ASSESSED xxxx xxx% xx)D( xnR xxxx I I ' S <br /> L <br /> I STATE StACKARGE FOR NEW FACILITIES ONLY • $18.50 is <br /> T <br /> Y s Tanks_ x58.00 1988 through 1990 ($56) 1991 through 1996 (256) 1997 <br /> SURCHARGE FOR 1997 XXXX%XX)OOR)ORXXX%XXXxx)p(p( xxxmccommumccuoum s <br /> C PERMANENT CLOSURE (RemoVaL Or AYthoritod Ctosura-in•PtaCe) TANK I.D. N(A) <br /> L <br /> 0 CLOSURE FEE • 578-00/hour (3 hours minimum/TANK) R TANK(s) X $04.00 = 5 <br /> T <br /> U TEMPORARY CLOSURE (Plan Raviw 6 Inspections) TANK 1-0- N(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours miniPWfACILITY) 2234.00 minimum i <br /> P INSTALLATION PLAN CHECK (Plan Review 9 Construction Inspections) TANK I.D. s(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 278.00/hour (8 hours miniPWFACi LITY) • 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review i ConstrWetien Inspections) TANK 1.0. R(s) <br /> E <br /> P TANK LINING REPAIR FEE a 278.00/hour (3 hours minissal/TANK) a TANK(s) x 5254.00 • S <br /> A <br /> I TANK RETROFIT REPAIR FEE n $78.00/hour (3 hours min./FACILITY) a 5234.00 mmmum 5 <br /> R <br /> PIPING REPAIR FEE a 578.00/hour (3 hours miniaWFACILITY) • SM.00 minissm, s <br /> N TRANSFER FEE a 520.00VNAUTHORIZED RELEASE EVALUATION - 278.00/hr I CYST 2 � A <br /> I <br /> S <br /> Cl CONSULTATION FEE = 278.00/hr I SAMPLING INSPECTION FEE = 578.00/hr I s <br /> TOTAL DUE 5 <br /> FOR OFFICE USE ONLY / <br /> — �T;1sy's. <br /> SUEEPS Y I COMPUTER t LOC COOE DIST CODE AN01BT RECEIVED I CHECK Y/ASN RECEIVED BY I DATE RECEIVED -' <br /> a <br /> k ^'Y11C1'A1. _ 'e'- AP r -..�IL•'Y s p,'5s— --r` 9K"..-r _ <br />