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SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> . FACILITY SITE NAME FACILITY CONTACT NAME <br /> o, nc4 !F l,M�W 5tb <br /> T -- <br /> rACll-ITY ADDRESS SITE PRONE / with AREA CODE <br /> ` t 2J40 _ 10:, eek <br /> I(Y f of TANKS I <br /> A , ( " <br /> a[ SITE <br /> P I U.F. <br /> D DDLICANT/BIILINC NAME PLICANT CONTACT ANE <br /> I i rider lnaerin r ;iN <br /> 1 — <br /> C MAILING ADDRESS PLICANT PHONE M WITH AREA CODE <br /> " USo 4 D`Of� venues to- 5N 'T CITY TYPE of APPLICATIONDSLAre.(Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 V <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ 1100.00 <br /> A XXXX XXXX loo too t Zio-o <br /> C <br /> I FACILITY PENALTY FEES ASSESSED (If Applicable) %XXX XXXX Jk-�o /C t pda <br /> I <br /> V TANK FEE _ 150.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> f Tanks = L 1986 1987 1 19881989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply a by fee for - <br /> A each year applicable) %XXX XXXX <br /> C <br /> I TANK PENALTY FEES ASSESSED 70(XX XXXX 1 5V -,s;nr) t <br /> l <br /> I STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H d S Code, Section 25287 <br /> T <br /> T f Tanks s t56-001988 through 1990 1991 through 1996 <br /> Amount Amot and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Piece) TANK LO. f(a) <br /> L ✓S <br /> O CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) f TANK(s) t X 5234.00 t 2 SA 5D <br /> S <br /> U TEMPORARY CLOSURE (Plan Review I. Inspections) TANK I.D. f(a) <br /> R <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimum/TANK) R TANK(s) X $234.00 = $ <br /> P INSTALLATION PLAN CHECK (Plan Review t Construction Inspections) TANK I.D. f(s) <br /> L <br /> A <br /> M PLAN CHECK FEE m 578.00/hour (8 hours minimm/FACILITY) = S624.00 minimus S <br /> R REPAIR FEE (Workplan Review d Construction Inspections) TANK I.D. f(s) <br /> E ---_ <br /> P TANK LINING REPAIR FEE - S78.00/hour (3 hours minimum/TANK) f TANK(s) X %234.00 = It <br /> A --_ <br /> 1 TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) - T234.00 minimum t <br /> R -- — <br /> PIPING REPAIR FEE • T78.00/hour (3 hours minim" /FACILITY) _ $234.00 minimus % <br /> M TRAmsrER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION $78.00/hr % <br /> I <br /> S — - <br /> C CONSULTATION FEE + 578.00/hr SAMPLING INSPECTION FEE = t78.00/hr S <br /> _ <br /> TOTAL ak f <br /> f <br /> FOR orrllrt USE M. DNIT <br /> £ F t�AI'ems�mi'��t=m'r-�-rr�rrmrin,mi 5. <br /> SUFF.PS f COMPUTER f LOC CODE DIST CODE AMOUNT <br /> /nRECEIVE HECK f C�ASN RECEIVED BY I DATE RECEIVEDMRlu� <br /> _...r..._. r { <br /> ..T,F-""i.� -S!'T , .:_...,d. ... ._�,i vrgym.. rr;o, gyri nl.�rri:3 <br /> J U C T <br /> IN 23 017 (REVISED 6-21-93) Page 11 <br /> �-Ao owe3'�za <br /> G q� 3 /so x 4 V- `�-�S f`'rr <br />