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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 FACILITY CONTACT NAME <br /> T hti <br /> 'E FACILITY ADDRESS Liza tuAi� VDja _Qr� .,......, <br /> SITE PHONE # with AREA CODE <br /> a0 J3 3k V) 1 1 <br /> CITY <br /> I1I T,�,Y, STATE ZIP CODE # of TANKS <br /> A <br /> W O I (�'� 'Z at SITE <br /> P APPL II /BILLING NAME - APPLICANT CONTACT NAME <br /> L <br /> I ° <br /> C MAILING ADDRESS <br /> APPLICANT PHONE # WITH AREA CODE <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> W L ,P, 9 C) (Closure, Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 1986 1987 1988 1989q,990C %XXX %XXX XXXX XXXX XXXXXXXXT FACILITY PENALTY FEES ASSESSED (If Applicable) ::f%XXX XXXX %%%% X%XX XXXXXXXX <br /> 1 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) <br /> E 8170/TANK (After January ,, 1991) -0.51 7cjl <br /> # Tanks = 1988 1989 1990 1991 1992 1993 1994 19951996 1997 1998 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX %XXX 70 <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ <br /> L <br /> 1 STATE SURCHARGE FOR NEW FACILITIES ONLY=$;N-51J'/V $ <br /> T <br /> Y # Tanks t1 x 88.00 1988 through 1993 (S56) 1993 through 1997 (S56) 1998 <br /> SURCHARGEFOR1998 XXXXXXXXXXXXX%XXX%XXXXXXXXX %XXXXXXXXXXXXXX%%%XXXX% g <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 = g <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = §78-06/hour-0 hours minimum/FACILITY) $234.00 minimum <br /> $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A / <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum <br /> t. <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) q 3(0. C v <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> 1 TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum g <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = S234.00 minimum g <br /> M TRANSFER FEE = <br /> 1 820.00 LT UNAUTHORIZED RELEASE EVALUATION = 878.00/hr g <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = S78.00/hr $a r///•D O <br /> TOTAL DUE 5 <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BT <br /> - DATE RECEIVED <br /> S <br /> EH 23 032 (REVISED 1-12-98) ..............................................................:..:.:.................................. <br />