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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH OIVSION <br /> U OUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTIff NAME Oa - .fi•�c <br /> IT O J4 r � � <br /> /a Aa/o /�f, <br /> E FACILITY ADDRESS <br /> /-Z, <br /> //� SITE PHONE # with AREA CODE <br /> & /-5,-/ So 7 N Ovl 4rN ST✓�v � 440c <br /> CITY STATE ZIP CODE # of TANKS <br /> PMao ee�It �!� F5, 3 at SITE I <br /> P APPLICANT/BInLLING NAME // APPLICANT CONT NAME <br /> L t /(P Q �� O✓ U✓ X70 vt C.o <br /> f <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A S, gam r ve yo8 3 �/ - <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> 9✓�OnB (Closure, Instal Lation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1986 1987 1988 1989 1990 <br /> A XXXX XXXX XXXX XX%% XXXX 5 Xxxxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX %XXX XXXX I XXXX XXXX 5 Xxxxxxxx <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) tAA`N .Z5'J� <br /> E <br /> # Tanks = 1987 1988 1989 1 1990 1991 1992 1993 1994 1995 1996 1997 <br /> F (multiply # by fee for <br /> A each year app(icabLe) %XXX XXXX XXXX XXXX XXXX I S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX I XXX% XXXX %XXX XXXX 5 ttLVu D'l;LS <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY - $18.50 'S .DO <br /> T <br /> Y # Tanks_ x 58.00 1988 through 1990 (S56) 1991 through 1996 (556) 1997 <br /> SURCHARGE FOR 1997 XXXXX%%XXXXXXXXXXXXXXXXxXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> W;ll <br /> C PERMANENT CLOSURE (Removalor Authorized Closure-in-Ptace) TANK I.D. #(s) a a 3. Sb b�tl <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) actAMO <br /> X $234.00 = S Q q ywdl.�F- <br /> S <br /> U TEMPORARY CLOSURE (PLan Review & Inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 878.00/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 /> H PLAN CHECK FEE - 578.00/hour (8 hours minimmVFACILITY) = 5624.00 minimum 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) # TANK(s) _ X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 8234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 5 <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE - S78.00/hr 5 <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> ei=-_`:':=:ii[:=:i!li5eie?:.4:,_Y.Ifi�" <br /> _u .S _..�—_.__._ T RECEIVED <br /> CASiel= EliRE ie=e::iiliii:i::::::::iiiSi <br /> !� SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH I RECEIVED BY � DATE REC.IVED - <br /> !� S <br /> ::u: e::ea:::a:::____...:.1110....—n':F __—�—_ _ _ _ <br /> :....... _aa :e�:us ,::=.r._ I.E. <br /> EH 23 032 (REVISED 5-27-97) • (' • <br />