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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> 5 FACILITY SITE NAME FACILITY CONTACT NAME <br /> 1 �-�.L;-rt- L+�l.l,• 7-t-Il:aJ�%T-� � i�l-Il � fall ! 'I arc i� <br /> T SITE PHONE # with AREA CODE <br /> E FACILITY ADDRESS .� G <br /> S STATE ZIP CODE # of TANKS -� <br /> CITY ) L.1 rl '7� ' at SITE <br /> 1 JI <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> 1 _ APPLICANT PHONE # WITH AREA CODE <br /> C MAI L4NG ADDRES (^{ (A _ ^� <br /> N <br /> T CITY r- _ STATE ZIP CODE TYPE of APPLICATION <br /> •..'�Y (Closure, stall 'Ln, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 ( •,( <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 XX%X %%XX XXXX XXXx XXXx 5 XXXXxxxxxxxxX <br /> A <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx XXXX xxxx %XXX xxxx s x%XXX%%%XXXX% <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = _ 5 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 6jVV�40363D <br /> F (multiply # by fee for <br /> A each year applicable) XXX% X%XX %%%% XXX% %K%% S �) �� <br /> C 5 <br /> I TANK PENALTY FEES ASSESSED xxxx XX%X XXXX %X%X X%xX <br /> L <br /> ) STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H d S Code, Section 25287 <br /> T <br /> T # Tanks x 556.00 1988 through 1990 1991 through 1996 (,�„y°t03533 <br /> (Enter amount and year) 5 ��t�• <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /> # TANK(S) X $234.00 = 5 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review d Inspections) TANK I.D. #(5) <br /> R S \ <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review b Construction Inspections) TANK I.D. #(s) <br /> L <br /> A a <br /> N PLAN CHECK FEE = 578.00/hour (8 hours mfnimm/FACILITY) = 5624.00 minimum1- <br /> R REPAIR FEE (workplan Review d Construction Inspections) TANK I.D. #(s) <br /> ES <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimus/TANK) # TANK(s) % 5234,00 = <br /> A S <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum <br /> R S <br /> PIPING REPAIR FEE = 578.00/hour (3 hours mininsnV FACILITY) 5234.00 minimus <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> 5S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br /> TOTAL DUE �- <br /> FOR OFFICE USE ONLY _ _ _ __ _ --- ' <br /> _.._.._._......!91m.^..'^!CF_?nman..tP_".!F..^.1.^.!.q!��g�n!ml?;:m .""_"y''._^..==1^N.^3EIY_' T'.m�nmgp..n!'C".'v_mm=...__.�.__ ___ __ _ _ _ <br /> ..._Tur::. <br /> ® SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED a <br /> a <br /> _ <br /> —m.m-:-- � '�JP='IEaeC9!'ET:JL;;T_v!i9:�i!4T.iiL^T^-e_c:'.m!?[-9:T.:s'!_-CL:�:6 =i.. ..:: ?W=! _ .�InnI Lh�'vT:L"=T�Ga '_�Ta <br /> anennna _ .. _ <br /> 9 <br />