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SAN JOAQUIN *LIC HEALTH SERVICES - ENVIRONMENTAL H4iSION <br /> U GROUND STORAGE TANK PROGRAM - FEE WORKSHEET i 7 Z <br /> TFACILITY SITE NAME I F FACILITY CONTACT "ELA (21 715 �M� <br /> r E FACILITY ADDR SS ' <br /> SITE PHONE N with AREA CODE <br /> - <br /> CITY r TATE Z P CODE 10 Of SITE P r� LA-L-a1J A . X153'20 <br /> P APPLICANT/BILLING NAME <br /> L APPLICANT CONTACT NAME <br /> �,-2 SI= ��. <br /> I (-L� a <br /> C MAILING ADDRESS <br /> A APPLI7T-PE—Qf <br /> T PHONE R WITH AREA C E <br /> N 55b Noe t4 Wks 3 �T CITYSTATE ZIP CODE APPLICATION <br /> 'V 2 (C(osure Installation, ate.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) : $100.00 1986 1987 1988 1989 1990 <br /> A <br /> C = <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX <br /> 1 : <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) <br /> E $170/TANK (After January 1, 1991) <br /> M Tanks = 1986 1987 1988 1989 <br /> f (multiply X by fee for 1990 1991 1992 1993 1994 1995 1996 <br /> JA each year applicable) <br /> C S <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX <br /> L I E S <br /> I STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H l S Code, Section 25287 <br /> T <br /> Y 9 Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> l <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimus/TANK) N TANK(s) X $234.00 <br /> S ��. . <br /> U TEMPORARY CLOSURE (Plan Review t Inspections) <br /> R TANK I.D. N(s) <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minim.R►/FACILITY) = S234.00 minimal <br /> S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. N(s) <br /> L <br /> A <br /> N PLAN CHECK FEE x $78.00/hour (8 hours miniman/FACILITY) = S624.00 minimus <br /> f <br /> R REPAIR FEE (Workplan Review a Construction Inspections) TANK I.D. N(a) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) 0 TANK(s) X $234.00 = <br /> A $ <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) _ $234.00 minilnua <br /> R S <br /> PIPING REPAIR FEE x $78.00/hour (3 hours minimnl/FACILITY) _ $234.00 minimus <br /> $ <br /> ICS <br /> TRANSFER FEE ■ $20.00 UNAUTHORIZED RELEASE EVALUATION x $78,00/hr <br /> S <br /> CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr <br /> $ <br /> FOR OFFICE USE ONLY TOTAL DUE <br /> ................7....q +i« »M»»»»p»{Aiiir:u:�►r y�c ••fir fit_ p_�{ �g <br /> »bc"S�1EE�`SAw C U�EN'p l(7( uls CLUE ` it JN`MwH.w A1M"�«.. ASI »»�»: »;»»�«: :: <br /> LIVED �I ' ox me <br /> a.. <br /> $ <br /> .......................... ........ ... ..... .... 0 S .. a <br /> ..... ...... <br /> ..... .. <br /> slr,mnwir,w�rxMw>wrmwcw► xwirmr w,wrnw,rmrmwawmr, ,�ww�le N NN �war w w w NW XX*a wa w,t, �r.:w ww wa.... <br /> w ,��w,wr�w M �*i <br /> EN 23 032 (REVISED 3-1-93) <br /> Pace 11 <br />