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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRCIDIENTAL HEALTH DIVSION <br /> U" -R(73ND STORAGE TAMC PROGRAM - FEE WORXSHEET <br /> SI FACILITY SI'ENAME ,^ FACILITY CONTACT NAME <br /> I !T 1 Y l 6 <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & .3 <br /> CITY r^, / / �� �WE� ZIP C006 � # of TANKS <br /> A J-'j—(�^� G K - at SITE <br /> P <br /> P APPLICAN /BILLING NAME APPLICANT CONTACT NAME <br /> L C�L <br /> I� <br /> C MAILING ADDRESS APPLICANT PPHONE, jWITH AREA CODE <br /> ly) <br /> T CITY TATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 11987 1988 1989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A ; <br /> C' <br /> T LFACILITY PENALTY FEES ASSESSED (If Applicable) XXXX I XXXX I S <br /> I <br /> VI TANK FEE = S50.00/TANK (Prior to January 1,1991) S170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 11988 1 1989 1990 1991 1992 1993 1994 1 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) I ; <br /> C' <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX S <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <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/TANK) # TANK(s) X 5234.00 = S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S O O <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minima/FACILITY) = S234.00 minimum S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr $ <br /> I I I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S 7 <br /> FOR OFFICE USE ONLY <br /> _.._........._...__.._...__...-----.._.__...—_._....---._._._.__..__—._..�__..._--._._.__. _-----.._._. _---------...._._.._...__........._.._.—_._........._..__.......__.._._........_....._..... <br /> SWEEPS # COMPUTER # LOC CODE I DIST CODE AMOUNT RECEIVED CHECK */CASH I RECEIVED BY I DATE RECEIVED <br /> as <br /> .. .............. <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />