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r1100000001 <br />05-21-1997 01:02AM FROM TO 19166464679 P.09 <br />SAN JOAQUIN C L1C HEALTH SERVICES - ENVIRONMENTAL HEALTHOION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />7�t. <br />FACILITY <br />SITE NAME �J� <br />FACILITY CONTACT NAME <br />TANK I.D. #(s) <br />L <br />E <br />FACT <br />ITY ADDRESS <br />0-731 <br />SITE PHONE # With AREA CODE <br />$78.00/haur (3 hours minimWTANK) <br />It TANK(s) _ X 8234.00 = <br />1986 <br />I F�.I �.Rj <br />1988 <br />L <br />1990 O. S O <br />ANNA <br />L FACfI <br />A <br />CITY <br />(Pion ReYfeW d Inspections) <br />)=X <br />S ATE <br />ZIP CODE <br /># of TANKS <br />P <br />'�, I, <br />TEMFXIARY <br />C <br />SURE FEE = 378.DO/hour (3 hours minimWFAC1LITY) <br />at SITE <br />P <br />APPL <br />CANT/8ILILING <br />Y FACI <br />ITY PEX4TY <br />NAME <br />APPLICANT CON ACT NAME <br />L <br />AIDC( <br />I= <br />I %XXX 5 %X%%X%XX <br />Pi <br />1 <br />oLg- <br />C <br />MAIL <br />NO ADDR� <br />SS <br />APPLICANT PHONE # NIH AREA COOS <br />K <br />0.00/TANX (Prior to Jarwary 1,1991) <br />8170/TANK (After January 1, 1991) <br />I 3 <br />T <br />CITY <br />STATE <br />ZIP CLUE <br />TYPE of APPLICATION <br />1986 <br />1987 <br />1988 <br />1989 <br />rj <br />( <br />1992 <br />(Closure, Installation, etc.) <br />1944 <br />C <br />PERWENT <br />TOTAL 1,U(/. <br />SURE (Reasrval or Authorised Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />0 <br />0-731 <br />RE FEE <br />$78.00/haur (3 hours minimWTANK) <br />It TANK(s) _ X 8234.00 = <br />1986 <br />11987 <br />1988 <br />1989 <br />1990 O. S O <br />ANNA <br />L FACfI <br />7Y FEE (Prior to January 1, 1991) = 8100.00 <br />ART CLOSURE <br />(Pion ReYfeW d Inspections) <br />)=X <br />)D= <br />)C= <br />XXXX S X)D=XXX <br />" <br />'�, I, <br />TEMFXIARY <br />C <br />SURE FEE = 378.DO/hour (3 hours minimWFAC1LITY) <br />SZ34.00 minimum <br />S <br />Y FACI <br />ITY PEX4TY <br />FEES ASSESSED (If Applicable) <br />XXXX <br />XXX% <br />AIDC( <br />I= <br />I %XXX 5 %X%%X%XX <br />I <br />V TANK <br />FEE = $ <br />0.00/TANX (Prior to Jarwary 1,1991) <br />8170/TANK (After January 1, 1991) <br />E <br /># Ta <br />ks = <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1944 <br />1995 <br />1496 -*' <br />O <br />F (mul <br />ip(y # <br />fee for <br />..l)v- 0-3 <br />)O= <br />XXXX <br />XXX)( <br />)Ccs <br />XXXX <br />)000( <br />S t� / U O <br />A each <br />C <br />year a <br />licable) <br />I TANK <br />PENALTY <br />FEES ASSESSED <br />I XXXX <br />XXXX <br />)0= <br />XXX% <br />XXXX <br />X)00( <br />S <br />L <br />I STAT <br />SVRCHA <br />7 <br />GE J = X <br />Y #TaiksEnt <br />1988 through 1990 <br />1991 through 1996 <br />1997 ,v(/ e.3 7 <br />r amau)IXand <br />Year) <br />XXXXXX%X%XXXXXX X)D0OD000O ( <br />��, f,` r S -7 ; �' `.-,_- <br />C <br />PERWENT <br />CL <br />SURE (Reasrval or Authorised Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />0 <br />CL <br />RE FEE <br />$78.00/haur (3 hours minimWTANK) <br />It TANK(s) _ X 8234.00 = <br />; <br />S <br />CHECK F <br />E = S78.00/hour (8 hours minim=/FAC)LITY) = $624.00 minim <br />S � <br />U <br />TEM <br />ART CLOSURE <br />(Pion ReYfeW d Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMFXIARY <br />CL <br />SURE FEE = 378.DO/hour (3 hours minimWFAC1LITY) <br />SZ34.00 minimum <br />S <br />P <br />)NST <br />LLAT)ON <br />PLAN CHECK (Pion Review 6 Corntruction lnspectiore) <br />TANK I.D. #(s) / _ T I- <br />LD <br />A <br />TANK <br />LINING REPAIR <br />FEE s $78.00/bour (3 hours minimWTANK) <br /># TANK(s) X 8234.00 <br />N <br />PLAN <br />CHECK F <br />E = S78.00/hour (8 hours minim=/FAC)LITY) = $624.00 minim <br />S � <br />R <br />REPA <br />R FEE (arkplan <br />Review 8 Conetruetion Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK <br />LINING REPAIR <br />FEE s $78.00/bour (3 hours minimWTANK) <br /># TANK(s) X 8234.00 <br />S <br />A <br />I <br />TANK <br />RETROFI . <br />REPAIR FEE = 278.00/hour (3 hours min./FACILITT) a $234.00 minfmum <br />S <br />R <br />PIPING <br />REPAI <br />FEE = ST8.00/hour (3 hours minioLMVFACILITT) . 5234.00 minimus <br />S <br />M TRAM FER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br />1 <br />5 <br />C CON UTATION FEE = 578.00/hr SAMPLING INSPECTION FEE - 578.00/hr S <br />C �� <br />r-x�cr <br />Toru DDE s <br />FOR OFFICE USE ONLY <br />COC CODE DIST CODE AMOUNT RECEIVCD CHECK #/CASH RECEIVED BY DATE RECEIVED <br />i <br />I S <br />� .--—.-�-Am�l osemsocm+eBsnwimn_n mmwv! <br />EH 23 033 (REVISED 4-24-971 <br />TOTAL P.09 <br />19 <br />