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SAN JOAQUIN TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL TH DIVSION <br /> 1.,..,ERGROUND STORAGE TANK PROGRAM - FEE WORKSHE_ <br /> S FACILITY SITE NAMEFACILITY CONTACT NAME <br /> I � Ct(G`/Y �fi(/_Tall <br /> Uy7 v"1 <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & <br /> dLlu Ke I+IrI�c� ,jug - 340G - /l <br /> CITY t STATE ZIP CODE # of TANKS _ <br /> A LC7(i ( Gtr 15 4 at SITE j <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> �" i <br /> I -' V <br /> C MAILING ADDRESS _ APPLICANT PHONE # WITH AREW tbDE <br /> A S T -2c - S 2 :1, s-� -A <br /> N <br /> T CITY / STATE ZI_P CODE TYPE of APPLICATION - -tC' I(,_trcxl :Sb <br /> II (Closure, Installation, etc.) In U <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX S <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 1992 1993 1994 1995 1996 <br /> F (multiply #Ty—fee for <br /> A each year applicable) XXXX XXXX $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX 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 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> E <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) n; �� On` �c 9*1lit�s) X $234.00 = $ a�lf,OL) <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) A)�. D) 7�� <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimus S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK 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 <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ G tX 4 31 <br /> A _ <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $-Lr U.D11 7 <br /> R J <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minima/FACILITY) _ $234.00 minimum $ �'I,u C) <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr $ <br /> TOTAL DUE $ �I . 06 <br /> FOR OFFICE USE ONLY :::•::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::-::::::::::::::::::::::::::::::::: <br /> .............................::::::::::::::..:........................................................................................................... <br /> SWEEPS # COMPUTER # LOC CODE DI$T CObE AMOUNT RECC1VEb CHECK #/UP RCCINI"D BV bAft RECIE VED <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />