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SAN JOAOUIN ^OUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAI -"ALTH DIVSION <br /> DERGROUND STORAGE TANK PROGRAM - FEE WORKS, <br /> S FACILI ITE NAME FA (CITY CONTACT NAME <br /> T <br /> E FACILITY ADDRESS S E PHONE # with AREA CODE <br /> a co2r�a I�o��e�J �d ¢�a <br /> CITY STATE ZIP CODE # of TANKS <br /> A (I�. at SITE <br /> P <br /> P APPC T/BILLIN NAME APPLICANT CONTACT NAME <br /> L G. RSL 2 <br /> 1 <br /> C MAILING ADDRESS APPLICANT HONE # WITH AREA CODE <br /> A k r2 CCS 59(n r2z <br /> N <br /> T CITY1 , STATE ZIP CODE TYPE of APPLICATION <br /> MCA a (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 - <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A %XXX %XXX %XXX %XXX Xxxx 5 %XX%XXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) Xxxx xxxx XXXX XXXX XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) - <br /> E <br /> # Tanks 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 <br /> = <br /> F (multiply # by by fee for <br /> A each year applicab(e) XXXx XXXX XXXX %XXX %XXX 5 (� <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX Xxxx XxxX XXXX %XXX u�lr'�p� 5 V720-00 QQ <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 �E <br /> T <br /> Y # Tanks_ x 58.00 1988 through 1990 ($56) 1991 through 1996 (556) 1997 <br /> SURCHARGE FOR 1997 %XXXXXXXXXXXXXXXXXXXXX%XXXX XXXXXXXXXXXXXXXXXX%XXXX E <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-i n-Place) TANK I.O. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimm/TANK) # TANK(s)_ X $234.00 = 5 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8, Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78-00/hour (3 hours minimum/FACILITY) 5234.00 minimum 5 <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 mini mum E <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> — <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /> # TANK(s) X 5234.00 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 mini mm S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minirtun 5 <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S <br /> I I <br /> S <br /> C CONSULTATION FEE = E78.00/hr SAMPLING INSPECTION FEE = S78.001hr S <br /> TOTAL Ol1E E <br /> FOR OFFICE USE ONLY __ ---- <br /> SWEEPS # COMPUTER # I LOC CODE DIST CODE AMOUNT RECEIVED (NECK #/CASH RECEIVED BY DATE RECEIVED <br /> g <br /> EH 23 032 (REVISED 5-27-97) 1 <br />