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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACIL TY SITE NAME FACILITY CONTACT NAME <br /> I l�aC r <br /> T G k �, <br /> E FACILITY ADDRESS s / SITE PHONE # with AREA CODE <br /> CITY STATE ZIP CODE # of TANKS <br /> AC04 i at SITE <br /> P <br /> P APPLICANT/BILLING N E APPLICANT CONTACT NAME <br /> Lri <br /> C NAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> NCITY STATE Z12 CODE TYPE of APPLICATION fees <br /> (Closure, Installation, etc.) P QJr <br /> TOTAL <br /> 1966 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A X00( )DOCK XXXX xxxx S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) X%RX %AXx xxn DOO(X S <br /> 1 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1 1996 <br /> F (muttipty # by fee for <br /> A each year applicable) XXxx <br /> C (�XXXX XXXX %X)= '70 1101176 5 .5/ b <br /> #S/ <br /> ITANK PENALTY FEES ASSESSED XXXX XXXX XX%X X%XX <br /> 1/1(91 /71) l s <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Cade, Se on 2 287 <br /> T <br /> T # Tanks x $56.00 1988 through 1990 1991 through Q996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> - <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s)_ X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum 3 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 8234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr 0253Y V S ab *-Al- <br /> Sl <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE Sign <br /> FOR OFFICE USE ONLY <br /> .._._..._........__......_._._..:__..................__..�.-,:_:::-__.__.....___.. ===r'-:::-._.-.......:.z::::::_:::::::....—,._._.__..__ _ _ _ _'— ___ <br /> ..........................._........... .......... __._.... ....... ..............._::_:._._-.......... .._.. ..___._....... <br /> ............._._._...._...._..____........:_..__..____._._.__._.....__:-..._..,_...,....._.....__....:::i:__.._._.._ ..........._..__..._.........._....__..__:�:::a_::�::.:.. ....... ... .. <br /> ... .......... <br /> a SWEEPS # I COMPUTER # I LOC CODE I DIST CODE I AMOUNT RECEIVED CHECK #/CASH I RECEIVED BY I DATE RECEIVED 9 <br /> 5 3 <br /> .z_: . _:::c __ _ _ _ <br /> .... .. .. .. ... :......:- __:_......... ....—_e... .: ammamia <br /> EH 23 032 (REVISED 4S� � li."iqb <br /> ."l <br /> V iii � �Q rs �- <br />