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SAN JOAQUIN PUBLIC HEALTH SERVICES - ENVIRONMENTA HE -7 <br /> UNDt..,OUND STORAGE TANK PROGRAM - FEE WORKS ET / <br /> S FACILITY ITE N E FACILITY E <br /> T <br /> �< < M%hcu CA <br /> E FACILITYADORESS��r l� �(eC� SITE P� ft-- <br /> 3q ODE S(I <br /> 8 6 <br /> CITY l TE ZIP CODE . <br /> PIt A <br /> ST SDG QS 0 <br /> P APPLICANT/BILLING NAME ,.� �� � <br /> LI <br /> APPLICANT CONTACT <br /> � <br /> C MAILING ADORES APPLICANT PHCNE # WITH AREA CODE <br /> Nb � p Iu� 9,5--7z <br /> T CITY ST TE ZIP CODE TYPE of APPLICATION Refum <br /> (j(,(� instal lat ion, etc.) <br /> D (Closure, (n.1 O <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A = <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XX)O( S <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # y fee for <br /> A each year applicable) S' D •oo <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX $ <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y 9 Tanks__L x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S�G.QO <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) 3 X S234.00 = S D� QC) h <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 minimum/FACILITY) = S234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S 6 a4 oo <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X S234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S C" <br /> FOR OFFICE USE ONLY <br /> °1zEEE7ferar'ut�I WW <br /> C �'awx'w� c <br /> 3Q1 ........» »..»...... »....21 <br /> »............ f .3...... <br /> M»M»MM»M» M»MM.�MrM»MMI►M.►MMM•M»MMN•M»MMI�M»M� )M►MMMtM►MM»MrM»MMI�MMIMIM:f410M�MrMM»MMtMMtMM�M►MIM�M»1MIy» MNI�}M�MM�MwiMM MI�M»MM»M»MI� <br /> EH 23 032 (REVISED 3-1-931 <br />