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- SAN JOAQUIN *Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL 0 DIVSION <br /> UN <br /> UNuERGROO STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY ST NAME FACILITY CONTACT NAME Bio <br /> T _ <br /> E FACILITY ADDRESS LIT I s ,I '' ` I th AREA CODE <br /> L 4�yPFRI Se 's pQr d 3 <br /> A <br /> CITY 0 vW 93 I at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> t �.. }�-� .b 1 <br /> I �C� L S fs 10- <br /> C MAILI AIRESS APPLICANT PHONE * WITH AREA CODE <br /> K 6 -7/ KZY0 <br /> i CITY STATE ZIP CODE TYPE Of APPLICATION <br /> (Closure, Instaltation, etc.) /L S <br /> TOTAL <br /> 148b 1487 1 1988 1989 1940 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> s <br /> c <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX $ <br /> I <br /> V TANK FEE = 150.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # ranks = 1986 1987 1988 1489 1990 1491 1992 1993 1944 1995 1996 <br /> F (multiply FEY fee for <br /> A each year applicabte) 5 <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX * <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Out every 5 years) Sea California H & S Code, Section 25287 <br /> T <br /> Y 0 Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> * <br /> C PERMANENT CLOSURE (Removat or Authorized CLosure-in-Ptace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimua/TANK) # TANK(s) X $234.00 ' S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review L Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPRY CLOSURE FEE a *78.00/hour (3 hours miniaWFACILITY) = $23 <br /> ORA4.00 minimum 5 <br /> P INSTALLATION PLAN CHECK (Pion Review i Construction IrrOpections) TANK I.D. #(S) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) $624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & CormtrUCtion Inspections) TANK I.D. N(s) <br /> E <br /> P TANK LINING REPAIR FEE = 378.00/hour (3 hours minimum/TANK) # TANK(s) <br /> A <br /> I TANK RETROFIT REPAIR FEE = 178.00/hour (3 hours rain./FACILITY) = $234.00 minimum S <br /> R PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) a $234.00 minimum $ <br /> M TRANSFER FEE - $20.00 UNAUTHORIZED RELEASE EVALUATION = 17$.00/hr S <br /> 1 <br /> S <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE ■ $78.00/hr * <br /> TOTAL DUE $ 23 y 'ML <br /> FOR OFFICE USE ONLY <br /> S2irlps�jtlNerlNi " awoda:►i�igw�7aciw8 woo bo:i«o�aoowiwdi�iaoi�>zoo"aootzm IoeeiaezTew�eiieiep►eeaa+r ei�iei>aeoo� o rx * ixWnn* <br /> �NY� w IR R�-REM <br /> s S � <br /> a = <br /> ► 5 <br /> �.......................... ........................ .................... ........................ .............. ............ .............................. .................................... ........................................ <br /> ]M.1.I.VMM M..JO.fiPMNiNMYIM7Y.iiiOiYPi91�iifif►%iPIf00A10iiiY1.0.iO4V%G9i.Y0i0i0.►YN.IV ii.i J.I/YV iYViA.�107�fYI.I�fY.fI.IMf..Ilf01.l.MMl.1.11.IM11.►fIY.N.A1.MMM.1I..1.MMMMIMIMMMl.lf1\i1MHRM101►MM <br /> .������(��rrwawwaw�"����.'��lNMIKlMI�ANMD AAIF�f AMi f11i711Mi� AipCAAY6C AAIiAM�Ti�gACAOY swsanrewmaacrwmawawm��mr�asaaefarrsrmaraatmrawwrmsas <br /> EH 23 032 [REVISED 3-1-93) Pace 11 <br /> 2:e•d 0t 2TL29T6T o.L w06--J Wb2T:TT Z66T—LZ—s0 <br />