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SAN JOAQUIN COUNTOLIC HEALTH SERVICES - ENVIRONMENTAL HEALTI`SION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME / " FAC LITY CONTACT NAME <br /> I r , / or QrSI <br /> T fJ rc�S <br /> 'E FACILITY ADDRESS SITE PHONE it uh AREA CODE <br /> a 3 ! £, as s 2a-- )-o -36 - 1-72o <br /> CITY STATE ZIP CODE # of TANKS <br /> A (7c )lG at SITE <br /> Pt22�Q tfJv <br /> P APPLICANT/8 LLING NAME, APPLICANT CONTACT NAME <br /> L , // o . fie.. <br /> C MAILING ADDRESS APPLICAllf PHONE At WITH AREA CODE <br /> W Z 2 e 2.6 3 � - Z0 <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> t5 <br /> -57;FJ (Closure, Installation, etc.) Q <br /> TOTAL <br /> 1986 1987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) 5100.00 <br /> A %XXX XX%X XXX% X%XX XXXX S %XXXX%X% <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX X%XX %XXX XXXX %XXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) (170/TANK (After January 1, 1991) <br /> E <br /> Al Tanks = 1_ 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 <br /> F (multiply # by fee for <br /> A each year applicable) %X%X X%XX %XXX X)(X% %XXX 5 <br /> C I g <br /> I TANK PENALTY FEES ASSESSED XXX% XXXX %XXX XXXX XXX% <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 E <br /> T <br /> Y # Tanks_ x 38.00 1988 through 1993 (556) 1993 through 1997 (556) 1998 <br /> SURCHARGE FOR 1998 X%%XXXX%%%XXXX%XXX%%XXXXXX% X%XX%X%%XXXX%X%XXXX%XXX 5 <br /> C PERMANENT CLOSURE (Removal or Authorized CloSure-in-Place) TANK I.D. #(S) <br /> O CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) I # TANK(s)_L X 5234.00 <br /> E <br /> U TEMPORARY CLOSURE (Plan Review 3 Inspections) TANK I.D. #(5) <br /> R <br /> E TEMPORARY CLOSURE FEE = 878.00/hour (3 hours minimum/FACILITY) (234.00 minimum E <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review S Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours mini /TANK) # TANK(s) % 5234.00 = E <br /> A <br /> I TANK RETROFIT REPAIR FEE = 878.00/hour (3 hours min./FACILITY) 5234.00 minimum 5 <br /> R <br /> PIPING REPAIR FEE = 878.00/hour (3 hours minimus/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr E <br /> I I i 1 <br /> S <br /> ClCONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr 5 <br /> TOTAL DUE s <br /> FOR OFFICE USE ONL7 <br /> _._..:_::::::�::_::::.:........._:. _...t....._... <br /> SWEEPS # COMPUTER # LOC CODE GIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED dY DATE RECEIVED <br /> i Ise:iiiiiiiii:i:::::::-:c::::::i:i_i:: <br /> FN JR n7 lRFVISEO 1-12-98) <br />