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' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL 4EALTH OIVSIGN <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T e 2 -7/n E L D/} r4i <br /> 'E FACILITY ADD ESS— SITE PHONE d with AREA CODE <br /> a oZP <br /> v STATEit of TANKS <br /> A CITY <br /> `/ ©G l /vyu C/+ ZIP CODE � at SITE <br /> P APPLICANT/BILLING NAME APPLICANT C011TACT NAME <br /> L <br /> I <br /> C MAILING DRESS APPLICANT PHONE x WITH A EA CODE <br /> A <br /> X <br /> 0. <br /> T CITY STATE ZIP CODE ( TYPE of APPLICATION Aold a-ri �J <br /> (Closure, Installation, etc.) <br /> t�"T fO TOTAL <br /> 1986 11987 I 1988 11989 1990 <br /> ANNUAL FACILITY FE=_ (Prior to January t, 1991) = 5100.00 <br /> Axxxx XXXX X)= XXXX XXXX 5 xxxxxxxx <br /> Ci <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) 1 xxxx XXXX XXXX 1 XXXX I xxxx S x%Xxxxxx <br /> 11 <br /> V1 TANK FEE = 550.00/TANK (Prior to lanuary 1,1991) 1 51701TANK (After January 1, 1991) <br /> :0 Tas E1� <br /> (multiply 6y fee for 11988 11989 i 1990 1 1991 11992 11993 11994 1995 11996 1 1997 1 1998 <br /> FI <br /> Al each year applicable) xxxx 1 xxxx I xxxx I xxxx lxxxx 1/70 1'-70 '7,0 111901 17o!170 S IoA000 <br /> I TANK PENALTY FES ASSESSED <br /> O G <br /> L! I XX%X XX%X XX%X I %XXX iXXXX I 1171 0101170 I <br /> II STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 S <br /> TI <br /> YI 3 Tanks x 58.00 1988 through 1993 (S56) 1993 through 1997 (S56) 1998 <br /> 1 SURCHARGE FOR '998 XXXXXXXXXXXXXXXXXXx(xxxxxxx %XxxxxMOO(x=xXxxxxxxx S O OO <br /> CI PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.0. 9(s) <br /> L' <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) 1 x TANK(s)_ x 5234.00 = S <br /> Si <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) 1 TANK I.O. $(a) <br /> R <br /> Ej TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimuNFACILITY) 1 5234.00 minimum S <br /> P! INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)1 TANK 1.0. x(s) <br /> Ll <br /> A <br /> X PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum 5 <br /> RI REPAIR FEE (Workplan Review & Construction Inspections) I TANK 1.0. Y(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I x TANK(s) X 5234.00 = 1 S <br /> A <br /> 11 TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum I S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum 1 S <br /> MI TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I 1 S <br /> I' <br /> ClSi <br /> CONSULTATION FEE = 578.00/hr 1 I SAMPLING INSPECTION FEE = 578.00/hr <br /> TOTAL DUE 'S( p 0 <br /> FOR OFFICE USE ONLY �l <br /> iUll <br /> SWEEPS S i COMPUTER LOC CODE DIST CODE AMOUNT RECEIVED CHECK */CASH RECEIVED 3Y I DATE .RECEIVED <br /> )_ S I l qlqlqy- <br /> EH 23 032 (REVISED 1.122-98)p <br /> tag C-/7 <br />