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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES�R#NME7ITAL ac"LTH DIVSION ✓" �� ` �r�� <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSItEET <br /> FACILITY SITE NAME n p F CILITY CONTACT NAME <br /> Y �� CJ�LLIS <br /> T l SITE PHONE # with AREA CODE <br /> E FACIA TY ADDRESS , <br /> d CITY I STUE ZIP CODE at SI TANKS <br /> �51 <br /> A T�2AG' C� 3�(0 <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME ,�L=IVIJI FC-VC. AT)OHK+�D� <br /> N Mfl <- <br /> ( APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A 2&H /Zor,(J J <br /> T GUYgjAPA STJ)TE 4q5- TYPE of APPLICATION, <br /> Gj{ r,J (CLosure, Installation, etaJ ov�6 <br /> (pj <br /> �) TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) 5100.00 XXXX X%XX /,90 E <br /> ALVI <br /> S / <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %%%% %%%% <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 2170 TANK (After January 1, <br /> 1991) <br /> E 1986 1987 1988 1989 1990 199 199 1993 1994 1995 199 <br /> # Tanks = <br /> F (multiply Mr fee for E/ °/ �,�(7 <br /> A each year applicable) %%XX XXXX Xy )(� 0 <br /> C <br /> 1 <br /> I TANK PENALTY FEES ASSESSED XX%X %XX% <br /> 1 STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H d S Code, Section 25287 <br /> Y $56.00 <br /> 1986 through 1990 1991 through 1996 E <br /> 56 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L # TANK(s) 1 X 5234.00 <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimm/TANK) y <br /> U TEMPORARY CLOSURE (Plan Review d Inspections) TANK I.D. #(s) <br /> R5 <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minirmm/FACILITY) $234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review d Construction Inspections) TANK I.D. #(s) <br /> L <br /> AS <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br /> R REPAIR FEE (Workplan Review d Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ X 5234.00 = <br /> A E <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br /> R S <br /> PIPING REPAIR FEE 578.00/hour (3 hours minimum/FACILITY) minimum <br /> MTRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> 5S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = E78.00/hr <br /> TOTAL DUE $ <br /> FO <br /> F 14.5 4!411 .... !...:=:.mmm-.: P. .......................::....._._!....._...__—. <br /> .�..__::......................_. ......_..................,..._.._..__ ......,.,,............._..,..:..... ..... . ....._.. 3 <br /> ° sWF'E�Os � coMPuTEk #- Lbc tDDE'`�-���DIST CODE AMDRJNY kECEIvED cdEcX #IcASIT kEtE�VED B! DATE�t{ cEi EC m <br /> a <br /> IR $ <br /> mmm <br /> 9) <br /> mmmT.mmNmmmmml........................:.._"_........._..__.... .._..._.........._..,....:, :::-......._...._..._............._..._.. <br /> .. .. _ <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />