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• <br /> SAN JOAOUIN OTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL OTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T tj'n 0 <br /> E FACILITY ADDRESS SITE PHONE I with AREA CODE <br /> 2-'-7 of V-V C 2,0c!) "-n-3--1 <br /> CITY STATE ZIP CODE * of TANKS <br /> 49G2-0-7 I at SITE <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L —7- <br /> CN I <br /> I 2A <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> Al L-i '4 <br /> Tj c; <br /> q CITY STATE ZIP CODE I TYPE of APPLI <br /> V2 <br /> ��� ( <br /> -1 j4 2 (Closure, etc.) <br /> C-A. <br /> TOTAL <br /> 1986 i 1987 1988 1989 1990 <br /> AlANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 - <br /> xxxx xxxx I xxxx S <br /> Tj FACILITY PENALTY FEES ASSESSED (if Applicable) xxxx I xxxx I xxxx <br /> 11 <br /> Vj TANK FEE = S50.00/TANK (Prior to January 1,1991) S170/TANK (After January 1, 1991) <br /> E I I <br /> F! 0 Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> (Multiply .1 by fee for <br /> Al each year applicable? <br /> XXXX xxxx xxxx S <br /> L <br /> 11 TANK PENALTY FEES ASSESSED <br /> xxxx I xxxx I xxxx I J S <br /> tj STATE SURCHARGE a S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> 1. Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> C1 PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) I TANK I.D. #(s) <br /> L, <br /> 7— <br /> 01 CLOSURE FEE mum <br /> = S78.00/hour (3 hours mini /TANK) TANK(S)_ X S234.00 = S <br /> S! <br /> UI TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. -.(S) <br /> R <br /> Ej TEMPORARY CLOSURE FEE a S78.00/hour (3 hours minimum/FACILITY) S234.00 minimum S <br /> F, INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. 0(s) <br /> Ll <br /> AlN PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> RI REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P,1 TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) TANK(s) X 5234.00 = S <br /> Al <br /> 11 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> MI TRANSFER FEE = S20.00 I I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br /> S1 <br /> C1 CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE S to,2-L-i <br /> FOR OFFICE USE ONLY <br /> E AMOUNT RECEIVED CHECK /CASH SWEEPS COMPUTER 9 LOC CODE DIST COD RECEIVED 3Y DATE RECEIVED <br /> S <br /> .......... <br /> N <br /> EH 23 032 (REVISED 4-29-94) <br />