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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> UNOERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITYWACT NAME / <br /> T - I <br /> E FACILITY ADDRESS Z �. S!lrvoL S SITE PHONE # with AREA CODE <br /> & c,0)) s 4 - =3476 <br /> CITY // STATEI ZIP CODE # of TANKS - <br /> at SITE <br /> P <br /> APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> o W- Gtil ST. <br /> T CITY STA�TE ZIP CODE TYPE of APPLICATION <br /> `CJ L> C4 —jlZLyly (Closure, Installation, etc.) <br /> a 15P 7— 6 TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX XXXX XXXX XXXX S xxxxxxxxxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (It Applicable) XXXX XXxx I XXXX %XXX XXXX s xxxxxxxXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,19911 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 11994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicab(e) XXXX XXXX XXXX xxxx xxxx ( 7b (70 1.701 l70 l9U / ;W S 0ZO <br /> C <br /> I TANK PENALTY FEES ASSESSED %X%X XXXX XXXX I XXXX XXXX ( 70 (7� 170 I 0 I /-0 (70 S (OZ-0 <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y At Tanks x 656.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-P(ace) TANK I.D. #(a) <br /> — <br /> Ll <br /> 01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X 5734.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum s <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.O. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 678.00/hour (8 hours minimm/FACILITY) = 5624.00 mini mm S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.O. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) At TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 5234.00 mini mm S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimWFACILITY) = 5234.00 minimum S <br /> MI TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr 5 <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr f <br /> %. TOTAL DUE S Zoe O <br /> FOR OFFICE USE ONLYN�• y z 7l O <br /> —SWEEPS # I COMPUTER # LOC CODE I DIST CODE AMOUNT RECEIVED CHECK #/GSH RECEIVED BY DATE RECEIVED <br /> IN <br /> ..................._.............__...__._.._.: <br />