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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL NEkMI DIVSTON UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET S I FACILITY SITE NAME*440q Faci(i iF 0 FACILITY CONTACT NAME 1987 11 Q`.dl 1989 T CHECK 578.00/hour hours = $624.00 1,5 E FACILITY ADDRESS SITE PHONE # with AREA CODE 1502 til. r-1 Pbr2jo (2L>q 9Co4 & CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) A CITY STATE QZIP CODE # of TANKS �cr, �,0 -1 at SITE A .Aon P %%x% xxxx P APPLICANT/BILLING NAME APPLICANT CONTACT NAME I �2NL iii ou Inc_ mai S isnivlo R C A MAILING ADDRESSAPPLICANT 1 10 w1how Pam *4Zp PHONE # WITH AREA CODE (SID) �ooR- 3 M TCITxx TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimun/FACILITY) STATE ZIP CODE TYPE of APPLICATION -Tlif -A a DUMP A (%.7r I FACILITY PENALTY FEES ASSESSED (If Applicable) ,j C,oncor-J GA 414520 (Closure, Ir*tallation, etc.)'PQ, jrYt, TOTAL C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) 1986 1987 1988 1989 1990 CHECK 578.00/hour hours = $624.00 1,5 ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 N 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = $ A XXXX %%x% xxxx XXXx xxxx S xxxxxxxx U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R C E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimun/FACILITY) $234.00 minimum S T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx %XXX XXXx %XXX xxxx S xxXxXxxx I V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) E # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 F (multiply # by fee for XXXX xxxx xxxx xxxx xxxx xxxx $ A each year applicable) C I TANK PENALTY FEES ASSESSED xxxx xxxx xxxx I xxxx xxxx xxxx $ L I STATE SURCHARGE _ T Y # Tanks x S8.011988 through 1990 1991 through 1996 1997 (Enter amount and year) XXX%%XXX)O=XXXXXXXXXXDCOO[ XXxXXXXXXXXXXXXXXXXXXXXIOOOI S C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) E L CHECK 578.00/hour hours = $624.00 1,5 N 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = $ A _ S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimun/FACILITY) $234.00 minimum S P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) E L Al CHECK 578.00/hour hours = $624.00 1,5 N PLAN FEE = (8 minimum/FACILITY) minimmx \ f,-,. R REPAIR FEE (Workplan Review & Construction Inspections) TANK ).D. #(s) E P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S A _ I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum $ R PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ TRANSFER FEE = $20.00 CONSULTATION FEE = 578.00/hr UNAUTHORIZED RELEASE EVALUATION = 578.00/hr SAMPLING INSPECTION FEE = S78.00/hr SWEEPS # COMPUTER # LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK #/CASH RECEIVED BY DATE RECEIVED EH 23 032 (REVISED 4-24-97)