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SAN JOADUIN COUR'",PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEX IVSIOM <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> S FACILITY SITE NAME n ya y <br /> 1 G/,vE o <br /> T SITE PHONE # with AREA CODE <br /> 'E FACILITY ADDRESS O�/�ONO Gr/r4y j-03pL <br /> &— Z, STAT ZIP CODE # of TANKS 3 <br /> A CITY LaO� at SITE <br /> P APPLICANT CONTACT E <br /> P APPLICANT/BILLING NAME <br /> L Of., <br /> I PLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS -5-2-19' <br /> ,9' <br /> A 3 O ,rCoui Caves [N O 7 <br /> N STATE ZIP CODE TYPE of APPLICATION Gz�o.$V&467 <br /> T CITY (Closure, Installation, etc.) <br /> Sj1jcG7dry 7�vci <br /> TOTAL <br /> 1986 1 1987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = SIOO.00 xxxx xxxx xxxx xxxx xxxx f xxxxxxxx <br /> A <br /> czxxx xxxx xxxx xxxx xxxx s xxxxxxxx <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I5170/TANK (After January 1, 1991) <br /> V TANK FEE • E50.00/TANK (Prior to January 1,1991) <br /> E <br /> # Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 11996 1997 1998 <br /> F (multiply # by fee for I t <br /> A each year applicable) xxxx xxxx xxxx xxxx xxxx <br /> C I I S <br /> Ij TANK PENALTY FEES ASSESSED xxxx xxxx xxxx xxxx xxxx <br /> L t <br /> 1 STATE SURCHARGE FOR NEW FACILITIES ONLY-$18.50 <br /> T <br /> Y # Tanks_ x $8.00 1988 through 1993 (556) 1993 through 1997 (S56) 1 <br /> 998 <br /> SURCHARGE FOR 1998 xxxxxxxxxxxXxxxxxxxxxxxxxxX %X%XX%%X%%x)(x%%xXx%%%%% <br /> t <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) LJA7�✓/JG�!� <br /> L # TANK(s) <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minim m/TANK) I % $234.00 <br /> STANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review 5 Inspections) <br /> RS <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) $234.00 minimm ! <br /> P INSTALLATION PLAN CHECK (Plan Review 3 Construction Inspections) TANK I.D. #(s) <br /> L <br /> Animus - $ <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) $624.00 mi <br /> R REPAIR FEE (Workplan Review b Construction Inspections) I TANK I.D. #(s) <br /> ES <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimm/TANK) # TANK(s) x 5234.00 <br /> A = 5234.00 minimus S <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br /> RS <br /> PIPING REPAIR FEE S78.DO/hour (3 hours minimum/FACILITY) f734.00 minimum <br /> M TRANSFER FEE <br /> _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr I S <br /> l � <br /> S = E78.00/hr I t <br /> Ci CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> eei:yw!,!!!,a,!:;!! � ...:. .!xw� =.-itte_ ."::':::,:!- ._._..:_...=:.y'r. _ RECEIVED <br /> 2Li!fi: !i.:....i,.uh:2uu..!n:..:._,us!axa::,�r.:.ua:.:::�:.a,,:o..: ram S*_v::1�I' Li!i]vCHE =mac/CASH k arm' <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED I CHECK #/GSH RECEIVED BY GATE <br /> 'T`Rm3i?^Bd5!..R!-!!.^.i1F. .c..:' .c:..:_...ev�_ea? ' 'e 3i—:iki_i2!Yi.e <br /> .__ ,ic_.,:L.ii - <br /> : <br /> 5^i:mD!n:91v c:F!22aie'w+.i!ti:!::!ruiiwc?`e Die:p:4li.ip:A:':-...a:::ek:c::: ::ccu6"-1! c;" � e::yi:P_:;::-iii!!!-im::.._ <br /> FH 73 hi7 nRFVISFD 1-12-98) <br />