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SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SFACILITY SITE NAME FACILITY CONTACT RAM�F,,, <br /> T I VI VRoLE�r e ►�bjzcr-) <br /> E FACILITY ADDRESS I 1 , C� SITE E # Mit�hJAREA CODE <br /> A CITY STATE ZI,s�3� # of TANKS r <br /> -t at SITE 5 �e... �� /— <br /> p � �v <br /> PI APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> Ll AN o&i-f o A- <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA COO <br /> N 1610 0"995VIc.L1 1� SD - -77B— �O C7 <br /> T CITY STAT ZIP CODE TYPE of APPLICATION BACk el-155� <br /> S0' (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = t100.00 <br /> OU vo OU ao 40 s SOD,o a <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX )O= 'm ' V z 0 f 3o Qr Od <br /> V1 TANK FEE _ $50.00/TANK (Prior to Jar%mry 1,1991) 2170/TANK (After January 1, 1991) <br /> E <br /> 4! Tanks = 1986 1987 1 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply At by fee for ��7ll <br /> A each year applicable) <br /> C lSo /o0 /'V l/sol/.no� �0 /a 2 Q ao <br /> / <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX S� I sv /S S/ Q o 0 s / 2, O <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x 956.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> 01' <br /> Cl PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours miniaLp/TANK) I # TANK(s)_ X (234.00 - s <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X 1234.00 - f <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 978.00/hour (8 hours minima VFACILITY) = $624.00 minimum t <br /> R REPAIR FEE (Workplan Review & Co truction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE - 178.00/hour (3 hours minimum/TANK) # TANK(s) X 1234.00 = f <br /> Al I <br /> ITANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) = 2234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 978.00/hour (3 hours minimum/FACILITY) $234.00 minimum S <br /> M TRANSFER FEE = 220.00 UNAUTHORIZED RELEASE EVALUATION - 178.00/hr f <br /> L <br /> 9 <br /> Cl CONSULTATION FEE _ &78.00/hr SAMPLING INSPECTION FEE - 178.00/hr S <br /> TOTAL DUE 376 0 <br /> FOR OFFICE USE ONLY <br /> SWEEPS At I COMPUTER # LOC CODE DIST CIE AMOUNT RECEIVED CHECK At/CASH RECEIVED BY DATE RECEIVED a <br /> 2 & 7� l I <br /> EH 23 032 (REVISED 11-1-92) Page 11 �; I C V `T <br /> r/ C/•M F <br />