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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIROIMENTAL HEALTH DIVSlON <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I AaY /k�s,j <br /> T SITE PHONE # with AREA COOE <br /> "E FACILITY ADDRESS <br /> Zv0 �• r.:� p <br /> A STATE ZIP CODE # of TANKS I <br /> CITY at SITE <br /> A Gay <br /> P APPLICANT CONTACT ONE <br /> P APPLICANT/BILLINGAME <br /> L416� p <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A .2t Zvcv L60f /�✓� <br /> N t STATE ZIP CODE TYPE of APPLICATION <br /> T CITY `OO / 1 0 (Ctosure, InstaLLation, etc.) <br /> TOTAL <br /> 1986 11987 1988 1989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 199U = 5100.00 Mxxxxx XXXX I xxxx I XXXX S xxxxxxxX <br /> A <br /> C X%XX I XXXX I x%XX )D= X%XX 5 %XXXX%Xx <br /> T FACILITY PENALTY FEES ASSESSED (I£ Applicable) <br /> I 5170/TANK (After January 1, 1991) <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) <br /> E <br /> TlTanks = 1988 1989 1990 1991 1992 19931994 1995 11996 11997 1998 <br /> Fti Ly # fee forA year a�cable) xxxx x%xx )(XXX <br /> xxXX Ixxxx 171 I /7- I/70 II"717 )moo 1170 S /OZJ <br /> C' <br /> I TANK PENALTY FEES ASSESSED I %XXX I %%%% XXX% %XXX (XXXX I)•jp I) 7/J I17p I i'7o I77p I-70 S /OZJ <br /> L S <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY-518.50 <br /> T <br /> Y # Tanks_ x 58.00 1988 through 1993 (S56) 1993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 I XXXXxxxxxxxXXXXX%%XXXX%XXXX X%XXXXXXXXXXXXXXX%XXXXX S <br /> CI PERMANENT CLOSURE (Removal or Authorized Ctosure-in-P(ace) TANK (.O. #(s) <br /> OI CLOSURE FEE = S78.00/hour (3 hours minimm/TANK) I V TANK(s)_ % 5234.00 = 5 <br /> 5 <br /> UI TEMPORARY CLOSURE (Plan Review 3 Inspections) TANK LO. #(s) <br /> R S <br /> E TEMPORARY CLOSURE FEE = S78-00/hour (3 hours minimum/FACILITY) I 5234.00 minimum <br /> P INSTALLATION PUN CNECX (P(an Review 3 Construction Inspections)I TANK I.D. #(s) <br /> L <br /> A S <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimm/FACILITY) = 5624.00 minimum <br /> RI REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I # TANK(s) _ % 5234.00 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimm 5 <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum 5 <br /> Mj TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I S <br /> I I I I <br /> S' <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S 7 c,4 D <br /> FOR OFFICE USE ONLY - <br /> ___ __ <br /> SWEEPS # COMPUTER # LOC CODE 0[ST CODE ANOINT RECEIVED CHECK */CASHI RECEIVED BY DATE RECEIVED <br /> LS <br /> EH 23 032 (REVISED 1-12-98) <br />