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SAN JOAQUIN COL' 'USLIC HEALTH SERVICES - ENVIRONMENTAL HEAL VSION <br /> UND. JUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT AME <br /> E FACILITY ADDRESS SITE P E # Vh AREA CODE <br /> CITY C A{ 1 A STATE ZIP CODE # of TANKS 7- <br /> P JI 111J� ��l �lU (. at SITE M <br /> L1 v O- KS-1 <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT -_ <br /> L <br /> C MAILING ADDRtSS c� APPI T P ONE # WITH AREA CODE <br /> N c''. ' . L OUB ��11 �l j �j O 933 -057c'-_, <br /> T CITY STATE ZIP C00_E TYPE of APPLI <br /> It J ( Cl sure, I tallatG,- etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1986 1987 1988 1989 1990 <br /> A <br /> S — - - <br /> r <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXX( S <br /> TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> x Tanks = . 1986 1 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply x by fee for <br /> A each year applicable) <br /> r $ <br /> I TANK PENALTY FEES ASSESSED <br /> inExxxx <br /> S <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y x TanksI 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 S234.00 = • <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 minimun/FACILITY) = 5234.00 minimus S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> AY � 41 <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S '�L,{ 51 0+i <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <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 = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R _ <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimus/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S -- <br /> II <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S -- <br /> TOTAL DUE f <br /> FOR OFFICEUSE ONLY <br /> �w.z.....,..»o... ..»r..... ....... .. . . .........»e... ..... ..... .r..»...........�...»»�...y.......�.....»... .......,........ .. .... .. .. .... ..............�.......�........»�.....z zZi we?S <br /> s <br /> s <br /> a <br /> " S a <br /> za zap xam�xa xarar r>Aa aawrc,ar xe�,rams tart aAaar aar,r�,u�aa>Aa�zmc xa awx���armor oar�f�aatc arraac,r�arowr�x�������zac awe taa�xraas a�,rwr��,wr aarc���aaoca>K <br /> EH 23 032 (REVISED 3-1-93) <br />