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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FAMCITY CONTACT NAME <br /> N y <br /> 13D nl �U D O , SR .GSJSL tnG• <br /> E FACILITY ADDRESS SITE PHONE M with AREA CODE <br /> CITY STATE ZIP CODE k of TANKS OSE D <br /> pP G T� .�_- \ Gp O at Ei7E <br /> P APPLICANT/BILLING NAME APPLIC NT CONTACT NAME <br /> L CIT o Srogk CIT 4AU. K 14 0,3 <br /> J: wo&,a <br /> 1 <br /> C MAILING/ADDRESS APPLICANT PHONE M WITH AREA CODE <br /> 4 <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> q0-L, (Closure, Installation, etc.) <br /> t✓ TOTAL <br /> 1986 1987 1968 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A 5 <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XX%% xxxx 5 <br /> 4 TANK FEE = E50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1 1) <br /> E <br /> x Tanks 1986 1987 1988 1989 1990 1991 1992 199 1994 '9"0' <br /> 1996 <br /> F (multiply M by fee for <br /> A each year applicable) 5 <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX �► S <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See C is H d e, ection 25287 <br /> i <br /> r 'anks x 556.00 1986 through 1990 M, 1991 [hr69 996 <br /> (Enter amount and year) PN ) r \N f <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) EN ANK I.D. x(s) <br /> L <br /> 0 CLCSURE FEE = S78.00/hour (3 hours minimum/TANK) 9 TANK(s)--L—_ % 5234.00 = 5 2 3d <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. $(a) <br /> R <br /> TEMPORARY CLOSURE FEE = S78.00/hour (3 hours miniaun/FACILITY) = S234.00 minimum s <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction InsPeetions) TANK I.D. 8(s) <br /> Ll <br /> A <br /> 4 PUN CHECK FEE = 578.00/hour (8 hours miniauN,FACILITY) = 5624.00 mini mm <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) XS23 . O = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) 5234.00 S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) _ x.00 mini" , l- S <br /> N TRANSFER FEE = %20.00 UNAUTHORIZED RELEASE S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SANPU NG INSPECTION FEE = 578.00/hr S --------- <br /> TOTAL DUE S2 3 4 <br /> -3 _ _ __ ____ _ <br /> FOR DEICE USE ONLY _ ___ _ _ ..._...._...._.._.._.__....__...._......._._......_.._...._........... <br /> ..................................................................._........_.........._......-........_............-.................. ............_. <br /> ClPITEi ' L'�7C" �D'E �Yi T's1r'L " A'FEV ` E ,S�� iY"'"", R'�f"` C�}V'�I��a <br /> A <br /> 3 <br /> -- -> rg5'1110 3-1-93) Pace 11 <br />