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SAN JOAQUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL H VSION <br /> UNDOIAiD STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SESITE NAME FACILITY CONTACT NAME <br /> T <br /> ADDRESS 1 /,( SITE PHONE # with AREA CODE <br /> S so <br /> CITY .�-- STATE ZIP CODE T# of TANKS <br /> A IL Cel at SITE <br /> P <br /> P APPLICANT/BILLING NAME APP ICANT CONTACT NAM <br /> L RMS ( Esrra�2 ��� � S .� <br /> I <br /> C MAILING ADDRESSAPPLICANT PHONE # WITH AREA CODE <br /> A 1� c7 . 19aY 252 Seo gZ6— 22-9 <br /> N <br /> TCITY STATE ZIP CODE TYP APPLICATION <br /> 1�L,eASArtsbn CA gq S(o6 Closur , Installation, etc.) <br /> TOTAL <br /> 1986 1987 11988 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 $ <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 # by fee for <br /> A each year applicable) XXXX XXXX S <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 1988 through 1990 1991 through 1996 .046 9 <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 = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ 7-34 oU <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L' <br /> A <br /> NJ PLAN CHECK FEE = $78.00/hour (8 hours minimm/FACILITY) _ $624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) �AtuV'l1NY ` <br /> P1 TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $23450 rl ` $ <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 mini&IAR 1996 s <br /> R >,1s! <br /> PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 i9 {�'r{ !`� �; $ <br /> `w, C <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr I DIVISI P!s <br /> I <br /> S <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr S <br /> TOTAL DUE s 'JJ 4 6• o� <br /> ��R OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH II RECEIVED BY I DATE RECEIVED <br /> _�s _.. J <br /> ._ _..._ _ — -......_. ..._..___.___._...__.____.__._ _._._......-.....__ <br /> :�_ _........_. ....................................................._:--::.. _........-:........... _._.._._. ._..........._._:.._-..........................::..........__.._........... _.__.._ .__. _.. <br /> __�_:�•_ _ : =•: :::::::::: ::::::::: ::::x.. ...---.....w_. _.....__ .• __:w::::::::::::::::: ::::::::::::::•s a :::::w: :: ...._.................:::_._ :... ......_._..: _ L� <br /> EH 23 032 (REVISED 10-28-93) _ •� � <br />