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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 %Qi G AS'r� {aL�.At"ee FACILITY CONTACT NAMES <br /> T o-9X lea cb-- &'(A.8<s(M GrL�T' <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> CITY � ` S�TnAT ZIP CODE # of TANKS <br /> A ��-lC�tnn (n at SITE / <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME ,/ // LL� <br /> �Gl� srf G,ve C/cl LCA"(;A,&, <br /> C MAILING ADDRESS AP LICANT PHONE # WITH AREA CODE <br /> A SOD L' . � . aoa -&Y - r <br /> N <br /> T CITY / _ /� STATE ZIP CODE TYPE of APPLICATION r3�tcic <br /> A1K kn �. ` r VA ,'()C/7Z (Closure, Installation, te.) <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A - ivo /(� vo- S SDD <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %XX% %X%% /CJ /CV U 5 <br /> I D D <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E / <br /> # Tanks = —L 1 1987 1 19 1 1991 1992 1993 1 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) SQ SU U SO ?O 7d /70 S 7�0O <br /> G <br /> I TANK PENALTY FEES ASSESSED XXXX KIM �Q � /?0 /70 �� S <br /> L <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H i S Code, Section 25287 <br /> T <br /> Y # Tanks/ x $56.00 1986 through 1990 1991 throng 1996 <br /> (Enter unt and year) / / <br /> — sCJ — <br /> 5 !l� <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) # TANK(s) X $234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = 5 <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(S) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimmVFACILITY) = 3624.00 minimum 3 <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minim LaVTANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> N TRANSFER FEE $20.00 UNAUTHORIZED RELEASE EVALUATION - 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE - 578.00/hr S <br /> FOR OFFICE USE ONLY TOTAL D <br /> ..........a........................_.......: ::i::::::_::::::::::::: <br /> :.:.._....a......m....:_..:..:.e...:v...s..-..x...............__...._..a....:......•.........._.....__—_..._.........._.._..r_—._:'_.-._.'.ai:�: _...:.z:.mc..:.r:_v::.:.uv'amL..:_T:::_ . ....... d .. �W?:.1.....:............... T .. w:::cucn :wn.m �. av_ iu'wa. <br /> / <br /> / <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED -� <br /> i <br /> n <br /> X59 /�✓f/.rif// D� 5 <br /> ................ <br /> ••••••••. .' :w.aa_.._. 'v�"s361!c_::c:wmd:m::wwwx'•• _�.._.... •:•=v!:iiiurt:: <br /> ......:c5ik=c!6:! <br /> .H.MN. ��a==�:v:64llG!L'v':_d.........;:.c:.._�_... IL!i!im <br /> EH 23 032 (REVISED 11-1-92) '-� "'n Page 11 <br /> z `7 <br />