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• e . <br /> SAN JOAOUIN TY PUBLIC HEALTH SERVICES - EUVIRORKENTALIPALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> E FACILITY ADDRESS SITE PHONE 9 with AREA CODE <br /> a <br /> 2-'-?0 1 r/ loci, "-13--1 3 3-7 <br /> A CITY I G JD.I C ISTATE PG 2-0-1 ICODE a of TANKS <br /> at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L� --T– <br /> C <br /> I <br /> CI MAILING ADDRESS APPLICANT PHONE 9 WITH AREA CODE <br /> A 2 $v Syr t',.s.e,- �3 1✓e3 . 20 t,o Z LA C--i &-i <br /> T CITYSTATE ZIP CODE TYPE of APPLIG N <br /> jp;Af'�G}'+� CA G;-1 y2 (Closure, �atio etc.) <br /> TOTAL <br /> 1986 i 1987 11988 i 1969 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> Cl XXXX I X)= XXXX ( 1 S <br /> TI FACILITY PENALTY FEES ASSESSED (If xppticable) ( Xxxx ' XXXX I XXXX ( I S <br /> V1 TANK FEE = S50.00/TANK (Prior to January 1,1991) S170/TANK (After January 1, 1991) <br /> Ei , <br /> I N Tanks = 1986 11987 i 1988 11989 ! 1990 1991 11992 1993 1994 i 1995 1996 <br /> FI (multipty 0 by fee for <br /> A! eacn year applicable) XXXX XXXX j XXXX I i I ( S <br /> C' - <br /> 11 TANK PENALTY FEES ASSESSED i XXXX I XXXX I XXXX I I , i i I 15 <br /> L: <br /> II STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T1, <br /> Yj I Tanks x 556.00 1988 through 1990 1991 through 19% I <br /> If CEnter amount and year) S <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. -'(s) <br /> L{ <br /> 01 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) TANK($) X 5234.00 = S <br /> S. <br /> UI TEMPORARY CLOSURE Celan Review & Inspections) TANK I.D. `'(s) <br /> t <br /> El TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) ( S234.00 minimum S <br /> P� INSTALLATION PLAN CHECK CPtan Review & Construction Inspections) TANK I.D. -'(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> EI REPAIR FEE (Workplan Review & Construction Inspections) ( TANK I.D. R(S) <br /> PI TANK LINING REPAIR FEE a 578.00/hour (3 hours minimum/TANK) I : TANK(s) X 5234.00 = S <br /> A <br /> II TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 5234.00 minimum I S <br /> R <br /> PIPING REPAIR FE=_ = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> MI TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION a S78.00/hr I S <br /> S i i i <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FE=- = S78.00/hr I S <br /> TOTAL DUE S .b Z Ll <br /> FOR OFFICE USE ONLY <br /> _._._._. <br /> SWEEPS COMPUTER 9 I LOC CODE I DIST CODE I AMOUNT RECEIVED CHECK A/CASH RECEIVED BY 4 DATE RECEIVED <br /> SAl <br /> EH 23 032 (REVISED 4-29-94) <br />