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_ ' <br /> SAN JOALUIN CCIJ. PUBLIC HEALTH SERVICES ENVIR &EX TAL HE. DIVSION <br /> U DERGRCUND STORJ►GE TANK PROGRAM - FEE WORI;SNEET <br /> SI FACILITY SITE NAME I FACILITY CONTACT NAME <br /> IJ & L Market owner <br /> FACILITY ADDRESS SITE PHONE 9 with AREA CCOE <br /> 3115 S . E1 Dorado St . 209-982-0397 <br /> PICITY STATE ZIP CODE ':t of TANKS <br /> French Camp Ica 95231 . sITE2Tanks 3 Products <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L J & L Market James Fisk , Owner <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE * WITH AREA CODE <br /> A 8115 S . El Dorado St 209-982-0897 <br /> N <br /> T CITY French Camp STAT�95231 <br /> ZIP CODE TYPE of APPLICATION <br /> a (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 11987 11988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XX:OC XXXX I S <br /> II FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX I =(x I I S <br /> Y TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> Tanks = 3 1986 i 1987 1988 11989 11990 1 1991 11992 11993 11994 11995 11996 <br /> F (multiply z by fee for <br /> A each year apps i cabs e) X 110 . 0 0 <br /> C' <br /> ITANK PENALTY 00(FEES ASSESSED I X) I )0= I I i I I S <br /> L <br /> I� STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Tanks z 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) '?t60--t995 - <br /> $168 . 00 <br /> Cj PERMANENT CLOSURE (RemovaL or Authorized Closure-in-Place) I TANK I.O. 4(s) <br /> L 1. <br /> 0� CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) 9 TANK(s) X 5234.00 = S <br /> S <br /> U41(s)TEMPORARY CLOSURE (Plan Review & Inspec:ions) TANK I.D. <br /> R <br /> E TEMPORARY CLOSURE FEE -- S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimus S <br /> P� INSTALLATION PLAN CHECK (Plan Review & Construction Insxc:ions) TANK I.O. ;*(s) <br /> L' <br /> A� <br /> NIPLAN CHECX FEE = S78.00/hour (8 hours minimLW FACILITY) = 5624.00 minim.mm s624 . 00 <br /> RI REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. ;*(s) <br /> E! <br /> P1 TANK LINING REPAIR F,E = 578.00/hour (3 hours minimum/TANK) 3 TANKCS) X 5234.00 = S <br /> A <br /> II TANK RETROFIT REPAIR FSE = S78.00/hour (3 hours min./FAC LITY) = S234.00 mini—m S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 miniaam S <br /> NI TRANSFER FEE = S20.00 I I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I I S <br /> i <br /> S. <br /> Cl CONSULTATION FEE = S78.00/hr I I SAMPLING INSPECTION FEE = S78.00/hr I I S <br /> TOTAL DUE s 13 0 2 . 00 <br /> FOR OFFICE USE ONLY <br /> SWEEPS 4 COMPUTER LOC CODEDIST CODE I AMOUNT RECEIVED I CHECX -/CASH I RECEIVED 3Y DATE RECEIVED <br /> EH 23 032 (REVISED 10-28-93) <br />