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SAN JOAQUIN rnUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> U GROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME / I FACILITY CORw(CT NAME PAYMENT <br /> T M-lki a cat-4 SGtY�S <br /> II <br /> E FACILITY AOORESS SITE PHONE # with AREA CODE E D <br /> fh Air + l� G 441 APR 0 9 1996 <br /> 3 T TE 21P CODE # of TANKS ��• JUIN OUNTY <br /> A CITY L q5a a' at SITE a PUBLIC HEALTH r"Rp'��E <br /> P 'LJ LTH DIVI <br /> P APPLICANT/BILLING NAME —I APPLICANT CONTACT NAME <br /> CI rd NAILING ADDR/E�SS� L refer �r-uca-Ion 5eLL� SclhredLl <br /> APPLICANT PHONE At WITH AREA CODE <br /> A O. 1-- x-785 ldl <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> /I I.,I�D � G�� -7 (Closure, Installation, etc.)1..� •J�� TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A X%XX %XXX %XXX %XXX XXXX S %XXX%XXX%%%XX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %XXX XXX% XX%% XXXX %%XX S X%%XXXX%XXXX% <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 11 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for 5 <br /> A each year applicable) %XXX %XXX XXX% I X7O% X%XX <br /> C S <br /> I TANK PENALTY FEES ASSESSED XXXX XX%X %XXX I XXXX XXXX <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California N 8 S Code, Section 25287 <br /> T1991 through 1996 <br /> Y # Tanks_ x $56.00 1988 through 1990 <br /> (Enter amount and year) 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.O. #(s) <br /> L # TANK(s) ^ X 5234.00 = 5 <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) _ate D •� <br /> STANK 1.0. #(S) <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R $ <br /> EI TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) SZ34.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review 8 construction Inspections) TANK I.O. #(s) <br /> L <br /> AS <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) . <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = <br /> AS <br /> 1 TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br /> R = $234.00 mini mm S <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br /> M TRANSFER FEE = 520.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br /> S <br /> I I <br /> S = 578.00/hr S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE 5 lv <br /> FOR OFFICE USE ONLY <br /> SWEEPS 9 JCOMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK /CASH <br /> RECEIVED BY GATE RECEIVED <br />