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SAN JOACUIN COUNT- ELIC HEALTH SERVICES - ENVIRONMENTAL HEALTP 'VISION <br /> UNDER AD STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SFA,C ITT SITE N NE FACILITY CON ACT E <br /> T �co �f�-('! � 71 <br /> E <br /> FACILITY ADORrSG(�/r ?O! -��r'n ,r ) SITE PHONE 4 with AREA CODE J 3 3 <br /> CITY O�� J l ST TE ZIP CODE CV 9 of TANKS <br /> A (� �� GQ at SITE <br /> P A.P-P�L-I•CAI T/BILL[ NAME APPL I � 7ACT NAIIEE// "/ �'� � f��, fW Gt�4f 1 -;r! �(1 ., <br /> C MA INC AD g Ss APPLICANT PHONE N WITH AREA CODE <br /> T CITY �' SJ¢TE ZIP CODE TYPE of APPLICATION <br /> �J (Closure, Installation, etc.)�e��� <br /> Toru <br /> 1986 11987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 <br /> A XXXX XXXX f <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) XXXX I XXXX I $ <br /> V TANK FEE = S50.00/TANK (Prior to J&-vary 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> Tanks 1986 1987 19925 11989 11990 1991 11992 1993 1994 11995 1996 <br /> F (multiply x by fee for <br /> A each year applicable) xxxx xxxx i S <br /> C - <br /> I TANK PENALTY FEES ASSESSED I XXXX XXXX I I 2 <br /> L <br /> 1 STATE SURCHARGE _ ?:56.00 each TANK (Due very i years) See California H & S Code, Section 25287 <br /> T <br /> Y I Tanksx 556.00 1988 Through 1990 1991 through 1996 <br /> (Enter amounC and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized C:osure-in-P(ace) TANK I.D. X(s) <br /> L <br /> 0 CLOSURE FEE - S78.00/hour (3 hours minim-n/TA.NK) I TANK(s) X 2234.00 = f <br /> S <br /> U TEMPORARY CLOSURE (P(an Review & Inspections) TANK I.D. x(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hcxxs minimum/FACILITY) 5234.00 minimum f <br /> P INSTALLATION PLAN CHECK (Plan Review & Car-struction Inspections) TANK I.D. 1(s) <br /> L — <br /> A <br /> N PLAN CHECK FEE = $73.00/hour (8 hours minimum/FACILITY) = S624.00 minimum f <br /> R REPAIR FEE ('workplan Review & Construction Inspections) - TANK 1.0. *(s) <br /> E —� — <br /> PI TANK LINING REPAIR FEE = S78.00/hour (3 `xmu-s minimum/TANK) k TANK(s) X 5234.00 = f <br /> A!l -- S234.00 minimum S <br /> Rf <br /> III TANK RETROFIT REPAIR FEE = S78.00/hour (3 ,'iour3 min./FACILITY) =- <br /> II PIPING REPAIR FEE = S78.00/hour (3 hours ninimlun/FACILITY) S234.00 minimum $ <br /> Nj TRANSFER FEE = S20.00 I I UNAUT:-iCRI7.ED RELEASE EVALUATION = S78.00/hr I f <br /> II - <br /> S <br /> C CONSULTATION FEE = S78.00/hr I I SAMPL:Y(; INSPECTION FEE = 378.00/hrFt <br /> f <br /> TOTAL DUE f <br /> FOR OFFICE USE ONLY _ <br /> _........._.._..._.............._......._..............._......_............... ----....._.._.._..._........ ............................... r-•--.- <br /> - -- - - — <br /> ~-SUEEPS t I CJMPUTER +' I LOC CODE I DISTE AMOUNT RECEIVED II CHECK !/CASH I RECEIVED 3Y DATE RECEIVED _ <br /> EH 23 032 (REVISED 10-28-93) 3 <br />