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��. Ll&&o SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION VD Hyl n�0 UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET S FACCLITY SITE�I NAME FACILITY CONTACT NAME I HCa �G 7`uo� Au T E FACILITY ADDRESS — SITE PHONE # with AREA CODE /JOY � . /YLG , Sy` 2 5Ye CITY cc STATE ZIP CODE # of TANKS A J Llc ✓7/�'t Cy} !15 Zv at SITE �. P P APPLICANT/BILLING NAME APPLICANT CONTACT NAME 1 C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE A S 3 Gw L T CITY STATE ZIP CODE TYPE of APPLICATION R CtCF (Closure, Installation, TOTAL 1986 1987 1988 1989 1990 ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 9ev A 00 /Ov IUU $ OU C D� T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX D OU "00 5 30c, I V TANK FEE = 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) E # Tanks = .2- 1986 1 1987 1988 1 1989 1990 1991 1992 1 1993 1994 1995 1996 - F (multiply # by fee for 3 cfyu 5V A each year applicable) /00 /O 00 y Y �7 I TANK PENALTY FEES ASSESSED XXXX XXXX ,341 !v /r7d pO -� : uv� L I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 T Y # Tanks�x $56.00 1986 through 1990 1991 through 1996 �OI (Enter amount and year) ' 1 C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANKM-52�— X $234.00 S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = $ P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) L A N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = 5624.00 mini num 5 R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) E P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S A I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum $ R PIPING REPAIR FEE = 578.00/hour (3 hours minimtm/FACILITY) = $234.00 mini mum $ J�6 4� o M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 5 0 I S C CONSULTATION FEE = 878.00/hr SAMPLING INSPECTION FEE = 578.00/hr TOTAL DUE $ ({'p FOR OFFICE USE ONLY ........................................................._......__......................_____....::::::-::::::-:_::_,:-::_,::— :-:::-.-:: :::--::-,:-:::::-:::::::::........_.._._......._......inti=iiii:::::=t"7 ..............................._....... .................. ._.............._.. ......................:.........._........................._.._..............:.:..:.._................::............... .......................t._......................_. ...................... .........................................::..:................. m..................__....:::..........................................................-..........................._....._._._..u. t ___........._. .............::::::::::...................... .............................................................. ...............__................. .,:..._........ ......._......__:'nuiiiiiiiiitmimi:ii:nnanimiiciini .............. ........................._..................................................................::-:::::::::..;..:::....: :....:..:::::�::::_::::...... ::::: r:3i=_i[[:aaia;:: ramicmtiawiiii;:=�_::�:.�_:: ::::::.:::..:..:::::::::ii:::niinimi;iii:in:::::_:� _.. ..::::::::::::::::::::::::::::::::::::::::::::::::u:::::::::::::::::,::::,..:__......:...... .:..:...:..:::a.u:......:...._....:::,:::.:::a...:.c::._::. =:ii- C PUT;N # OC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED H.3L scr 3__..._. ._ ...__....L...._....._.....____..........._..._....................._.....__........,........_..._................_..........,: .....::.:::........._.._.......................................... n:= u![i_iii---n._ EH 23 032 (REVISED 11-1-92) Page 11 �\