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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH D(VSION T/) v � S <br /> UNDERGROUND STORAGE TANG PROGRAM - FEE YDNKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I G rc� .. d /-�u-fa <br /> T <br /> E FACILITYEADORESS SITE PRONE # with AREA CODE <br /> t <br /> op v0 Al . Ca / �o.� « s/0 - .5 �� -JS7r2� <br /> CITY / STATE ZIP <br /> CODE i of TANKS <br /> A SXv c./C Az, - 9 S 20 Z et SITE <br /> P <br /> P APPLICANT/BILLING NAME C _ APPLICANT CONTACT NAME, / <br /> L u`n s-�vPr fn v, -s L.I"& Crc �4Cs-.q Pa <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> T CITY �Q STATE ZIP CODE TYPE of APPLICATION <br /> k5,*.e 4 tA.Joodl C/4 9 y�'/ (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1967 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A wx 7000( f <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX X)00( 5 <br /> ( <br /> V TANK FEE - S50.00/TANK (Prior to January 1,1991) S170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = / 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fas for <br /> A each year applicable) XXXX 1000( (aV� oo /�� 5 3(eD <br /> c <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX 00 p 5 3:v i7 <br /> L <br /> I STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See California N i S Code, Section 8287 <br /> T <br /> Y # Tanks X 556.00 1988 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. #(a) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimm/TANK) # TANK(s)_ X $234.00 - f <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(a) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X 5234.00 - S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(a) <br /> L <br /> A <br /> N PLAN CHECK FEE - 578.00/hour IS hours minimMVFACILITY) = $624.00 minimum S <br /> R REPAIR FEE (Workplan Review S Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE - 578.00/hour (3 hours minimun/TANK) # TANK(s) _ X $234.00 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) - 5234.00 minimum 5 <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) _ (234.00 minimum S <br /> N TRANSFER FEE _ (20.00 UNAUTHORIZED RELEASE EVALUATION - S78.00/hr S <br /> I <br /> 5 <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE - S78.00/hr 5 <br /> TOTAL DILE S '7 <br /> FOR OFFICE USE ONLY S fZ- O�S6y 11v v u tt •` 3S <br /> - .... <br /> SWEEPS # COMPUTER >/ LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/GSH RECEIVED BY DATE RECEIVED <br /> 3 <br /> 3rRs� sv� o 'z3 j S . I Is� :. .. <br /> _..:_.— _ -_ <br /> EH 23 032 (REVISED 6-21-93) Page 11 <br />