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SAN JOAQUIN COUNTY P.. AC HEALTH SERVICES - ENVIRONMENTAL HEALTH I. low <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SITE NAME FACILITY CONTACT NAME <br /> SrT v TT�vcr�r�ir, Ite=e C,1 IS <br /> FACILITY ADDRESS ITE P NE N with AREA COD <br /> PWFACILITY <br /> � �/ - vlZ 3 <br /> CITY STATE ZIP CODE N of TANKS <br /> at SITE <br /> P J l/. <br /> P APPLICANT/BILLING AME APPLICANT CONTACT NAME <br /> V � B� �rlc c Ate/ ��c ddE- <br /> I LICANT PHONE N WITH AREA CODE <br /> C NAILING ADDRESS <br /> A ( 7 ( i—n ti — tc <br /> N STATE ZIP CODE TY of APPLICATION <br /> T CITY % Jf- / Cj lL sure,/Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 S <br /> A <br /> C xxxx xxxx 2 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I $170/TANK (After January 1, 1991) <br /> V TANK FEE • 250.00/TANK (Prior to January 1,1991) <br /> E <br /> M Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply M by fee for 2 <br /> A each year applicable) <br /> C 2 <br /> 1 TANK PENALTY FEES ASSESSED xxxX %XXX <br /> L <br /> I STATE SURCHARGE = 256.00 each TANK (Due every 5 years) See California H 6 S Code, Section 25287 <br /> T1991 through 1996 <br /> Y N Tanks_ x 256.00 1986 through 1990 <br /> (Enter amount ercl year) 2 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. N(s) <br /> L N TANK(s) % 2234.00 2 <br /> 0 CLOSURE FEE = 278.00/hour (3 hours minimum/TANK) <br /> S TANK I.D. N(s) <br /> U TEMPORARY CLOSURE (Plan Review d Inspections) <br /> R <br /> E TEMPORARY CLOSURE FEE • 278.00/hour (3 hours minimum/TANK) N TANK(s)_ % $234.00 2 <br /> P INSTALLATION PLAN CHECK (Plan Review 6 Construction Inspections) TANK I.D. N(a) <br /> L <br /> A = 2624.00 minimum S <br /> N PLAN CHECK FEE = 278.00/hour (8 hours minimum/FACILITY) <br /> R REPAI!REPA!IRFEE <br /> an Review B Construction Inspections) TANK I.D. N(a) <br /> E S <br /> P TANK FEE • t78.00/hour (3 hours minimum/TANK) N TANK(s) _ x 2234.00 = <br /> A S <br /> t TANK IR FEE • 278.00/hour (3 hours min./FACILITY) 5234.00 minimum <br /> N = 5234.00 minimum S <br /> PIPIN = $78.00/hour (3 hours mintom/FACILITY) <br /> NTRA NSFER FEE = 220.00 UNAUTHORIZED RELEASE EVALUATION - 278.00/hr 2 <br /> 1 <br /> S2 <br /> C CONSULT�- $78-00/hr SAMPLING INSPECTION FEE • 278.00/hr <br /> (' TOTAL DUE S <br /> t OFFICE USE ONLY <br /> mmn„n!nncum!munmmenxmnurenmmmxu!mnm::xuu"•muu�u!,mmmmmmum !wmmmti! w"u''ia;wdt' n9� miu m"iwno°ruimmiinwu.,iiosealiw'�!u'�m"lfr-u,u�,''i�r5 ku yi <br /> n!xn..=.ruqunnn��!!:nnn;!;n,mmm�,mmm. <br /> N anm!:cauun!!!mngx!!xmmmma nuunewuuxw!umannnw!muumumunnm!�umuanm,!m!wmnnuuu,m,axcwmdl�wle!!m!u'�iim !mnm! <br /> SWEEPS N COMPUTE0. N LOC CODE DIST CODE AMOUNT RECEIVED CHECK N/CASH RECEIVED BY DATE RECEIVED <br /> a <br /> mm 'uu!ifti!xonuuliimm"iiivmAf'i ''ue'mmc�u�wuue°u�im,iiiiim," vruini,mii:iio <br /> xilwili' itil itl�uun� 6hW,"H'mwfiliTu'GP'ani"J1!rm�timi'!Cnu��iu uu1 1!mnuwu uw <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />