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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIMON <br /> UNDERGROUND STORAGE TANK PROGRA14 - FEE WORKSHEET <br /> .<.'� FAC I:..ITY SITE NAME FACILITY CONTACT NAJ$., <br /> T I v F v Ro US-r e t'6alz6-s- <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> s f I s r � ql yl/� g 3 3 <br /> CITY STATE ZIP CMF2 # of TANKS <br /> A `i 1 F q 7� at SITE 3 Z pfv—.. � ✓ /�S1 `'' <br /> PI APPLICANT/BILLING NAME ONT <br /> APPLICANT CACT NAME ���\\ 1� <br /> O U /� 7TtO <br /> Pr S <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA COD <br /> NC[T1610 OMF�SVILL� D SD - -773"— O^/J7'�00 <br /> T Y �( STAT ZIP CODE TYPE of APPLICATION P!'k_k e1:5!5_ <br /> 1N �T 0 (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1 1988 1 1989 1 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A <br /> UU 0 OU 00 DO S -!5;--242.d b <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) XX%X 1 'C= I DD14 MI/00 $ 3D O. Od <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> $ Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for �-yl <br /> A each year applicable) <br /> C /SQ <br /> I TANK PENALTY FEES ASSESSED 1 XXXX %XXX S� 1 SU /SWSA O ri 0 S / �' ae <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y S Tanks K S56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) 1 TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minim n/TANK) I # TANK(s)_ X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 - $ <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK 1.0. #(s) PAYMENT <br /> L <br /> Al RECEIV D <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimcm/FACILITY) = 5624.00 minimi <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) SAN JQAQUIN C <br /> ES Pi Wili K, vp <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) _ 6N�pAOENTALHEAL FtDIVI$ON <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) 5234.00 Mini mm S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimun/fACILtTY) • S234.00 minimum S <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED REL-EASE EVALUATION = $78.00/hr $ <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE . S78.00/hr <br /> TOTAL DUE 376 0 <br /> FOR OFFICE USE ONLY <br /> _3 SWEEPS # I COMPUTER At I LOC CODE I DIST CO9E I AMOUNT RECEIVED I CHECK #/CASH I RECEIVED eY I DATE RECEIVED a <br /> 3 <br /> 2 SIDiSc/ vin-,I 3 2 $ <br /> EEA 23 032 (REVISED 11-1-92) Page 11 <br />