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SAN JOAQUIN a 'TY PUBLIC HEALTH.,SERVICES - N IRONNEATAL S TN DIVISION <br /> L---AGROUND STORAGeTANK P&GRAN - FEE UORKSHEi l <br /> IFACILITY SITE NAME , ]ND [i2yE ' , ) FACILITY CONTA AME <br /> T v v W <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> CITY STATE ZIP LODE # of TANKS <br /> A I at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP 60DE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A )O= XXXX xxxx X)= p $ /040) <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) X)= XXXX XXxX XXXX Oct S /00 <br /> I <br /> V TANK FEE $50.00/TANK (Prior to January 1,1991) 170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks = � 1986 1987 1988 1989 1990 Ml 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX xxxx xxxx /00 3 C+ /�QO d <br /> C �/ u� <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX /00 T� �.lu 3 � Td � $ l QO&j <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See Cali ornia H & S Code, Section 25287 <br /> T <br /> Y # Tanks 7 'x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> o� �z <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-inPlace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) Z X 5234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I t 234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) iANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) $624.00 minimum $ <br /> R REPAIR FEE (workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E I- <br /> P TANK LINING REPAIR .FEE = $78.00/hour (3 hours minimum/TANK) 8 TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) $234.00 minimum 5 <br /> R <br /> PIPING REPAIR FEE = 378.00/hour (3 hours minimum/FACILITY) 5234.00 minimum $ <br /> 11 TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S --— <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ <br /> TOTAL DUE $ �. <br /> FOR OFFICE USE ONLY <br /> _::::::::_.c-- - .-saa'v:;;;;il:ii:`na:a:r:�• :—•�.�...-»^:.»^�:»^.. _'-i=_•b;;;i�i » ' . <br /> ^ 'w""�•u:a..—:_•,-:::;;,.„ <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED HECK #/CASH RECEIVED BY DATE RECEIVED <br /> $ _ <br /> --=--15M <br /> EH 23 032 (REVISED 4-6-95) <br />