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SAN JOAQUINTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL TN DIVISION <br /> U OUNO STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME ®� <br /> I a t �/'n V <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> CITY �^ STATE ZZIIP CODE # of TANKS <br /> A `-� C/g !Jr-o� �- at S I TE ( ®/) <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I v /' CC <br /> C MAILING ADDRESS APPLICANTT PHONE # WWITH AREA CODE <br /> r <br /> A . 8 3 7 3 tS <br /> N <br /> T CITY STATE ZIP CODE TYPE of A�InstalLation, <br /> (Closureetc.) s <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX S XXXXXXXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 3 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX x $s- Q <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX 5 <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 -3 x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) / <br /> $ �b <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum 5 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum 5 , <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr $ <br /> TOTAL DUE 5 /se <br /> FOR OFFICE USE ONLY <br /> :::::::::::::::::::::::::::::::::::::::::::ss:::r.:r.:::•:r._................................ .....».................... .. ....»...«....«....«............«...«. ........ ............_...... .«...«.............._.........».. ........ <br /> •.:.......:........:..s:............._...:m................«.........:::a.r.:......:......:..:..............r................ ........rs.......»......_....»r.. »:n: ..._.............«...............r..«.... s.nr......:...e::r.-.........;........ <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> ............ ............................................................ .....................«. _«.._ r..M.:::::s:::•::«::::r.:^:n:mr.:rn:::s:s:::.............«...... <br /> ._._...... <br /> .............................................................................................................................................»................s..:........................«...............«..................................sr...»._........_.........»....ss.:.:...............s........................:........... <br /> .s:.... .r. .._....««..«...... <br /> �:::::r.......................................:........................................................................... ....«. ......:s:...s:...................«. <br /> ...«.:._ ...................r::::::::......................................................... <br /> 9 <br />