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SAN JGAOUIN COUNTY PUBLIC HEALTH SERVICES - ELVIRONIHENTAL HEALTH OIVSICN <br /> uwFRGRCL= STORAGE TANK PROGRAM - FEE wORKSHEET <br /> Sl FACILITY S1TE NAME FACILITY CONTACT NAME <br /> 1 Q <br /> T SITE PHONE 3 with AREA CCOE <br /> "E FACILITY ADDRESS <br /> a G <br /> A CITY OG I S-i ZIP CL'DEO5 X of TANKS <br /> `�^F)1 J/ at SITE <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L T ( G <br /> I I APPLICANT PHONE 0 WITH AREA CODE <br /> CNALLIN5ADDRESS � <br /> A /' 0 5 ao9 S <br /> NI�iATE ZIP CODE TYPE of APPLICATION 1 <br /> T CITYAA� lure osInstaLlation, etc.) 1 <br /> of TOTAL <br /> 1986 11987 11988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 19911 = 3100.00 xxxx XXXXI XXXX i XXXX S XXxxxxxx <br /> Al XXXX <br /> CI Xxxx I XXXX I xxxx I XXXX I XXXX s xxxxxxxx <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> II 5170/TANK (After January 1, 1991) <br /> v TANK FEE = SSO.00/TANK (Prior to January 1,1991) <br /> E <br /> 3 Tanks = 1988 1 198911990 11991 1992 11993 11994 11995 ! 1996 17997 1 7998 <br /> F (multiply S by fee for <br /> A each year applicable) XXXX I xxxx I XXXX I XXXX !XXXX A- <br /> C �} <br /> I TANK PENALTY FEES ASSESSED I xxxx I XXXX I XXXX I XXXX IXxxx I � �'�i{/yi(/L I I S <br /> ` 1IMIO.00 5 ID°� <br /> L STATE SURCHARGE FOR NEW FACILITIES LI7IE5 ONLY=3 <br /> T q 00 <br /> T d Tank�FOR <br /> 0 1988 through 1993 (556) 1993 through 1997 (556) <br /> SURCHX%XXXX%%XXXX%XXXXXXXXXXXXX% %XXXXXX%XXXXXXXXXXXXXXX I I <br /> U <br /> Cl PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) I TANK C.D. 9(s) 5I <br /> 1 34 <br /> OI CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) S TANKCS)_ X 3234.00 - S <br /> S TANK I.O. i(5) <br /> U TEMPORARY CLOSURE (Plan Review 3 Lrepec:lore) <br /> R5 <br /> E TEMPORARY CLOSURE FEE = 378.00/hour (3 hours mini mim/FACILITY) I SZ34.00 minimum <br /> PI INSTALLATION PLAN CHECK (Plan Review S Construction Inspections) TANK 1.0. +"(s) <br /> L <br /> A5 <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY)LTY) = 5624.00 minimum <br /> R REPAIR FEE (Workplan Review 3 Construction Inspections) TANK L.O. 4(s) <br /> E52341S <br /> P TANK LINING REPAIR FEE = 578.00/haur (3 hours minimum/TANK) I $ TANK(s) _ X .00 <br /> A5234.00 mi15 <br /> [ TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = minimum <br /> RI S <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimus/FACILITY) = 5234.00 mini mum <br /> MI TRANSFER FEE = $20.00 I UNAUTHORIZIu"7 RELEASE EVALUATION = 5$.00/hr I I <br /> Ii <br /> I <br /> SS <br /> CI CONSULTATION FEE = 378.00/hr I I SAMPLING (NSPECTICH FEE = 578.00/hr I <br /> TOTAL DUE 5 <br /> FOR OFFICE USE ONLY <br /> SWEEPS 3 I COMPUTER d I-LCC7E FOIST CODE I AMOUNT RECEIVED CHECK */CASH I RECEIVED dT GATE RECEIVED <br /> -98) <br /> EH 23 032 (REVISED 1-12 <br />