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SAN JOAQUIN COUNTYAWIC HEALTH SERVICES - ENVIRONMENTAL HEALTHAWSION UNDERG STORAGE TANK PROGRAM - FEE WORKSHEET S FACILITY SITE NAME FACILITY CONTACT NAME I /yiAL( c v. S . i�. /� �l✓YGsr�r T 'E FACILITY ADDRESS SITE PHONE # with AREA CODE 66c, M l fSEGL Sr- l""+) &'7-6 -3z vu 8 CITY STATE ZIP CODE # of TANKS F �/jJ—, t1.c�7 1715�3G at SITE Z P APPLICANT/BILLING NAME APPLICANT CONTACT NAME L I C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE A N TI c),, , STATE ZIP CODE TYPE of APPLICATION (Closure, tnstallation, etc.) TOTAL 1986 1 1987 1988 11989 1990 ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 A %XXXXX%% X%XX XXXX %XXX S %XXX%%%% C T FACILITY PENALTY FEES ASSESSED ((f Applicable) %%%K %%XX %%%% XX%% %%%% S %%%X%%%% I V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) E # Tanks = _Z� 1988 1989 1990 1991 1992 1993 1994 1995 11996 1997 1 1998 F (multiply # by fee for A each year applicable) XXXX %XXX XX%X XXXX %XXX 5"1U yw j4/v 13yv S+, jG S2J&J,0. 0 t, C I TANK PENALTY FEES ASSESSED xXX% %XXX X%xX %%%% XXXX -5,/v "S��O "�'><� 12f� 'S`I� �9/a SZJ u"Jo. +u• L 1 STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 S T Y # Tanks U X 58.00 1988 through 1993 ('66) 1993 through 1997 (556) 1998 SURCHARGE FOR 1998 XXXXX%X%X%XXX%%%XX%XXXXXXXX XXXX%X%XXXXXXXXXXXX%XXX E S G_ CIL) CI PERMANENT CLOSURE (ReImOVat or Authorized Closure-in-PLace) I TANK I.D. #(s) L 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) it TANK(s) X 1234.00 = S S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE - 578.00/1hour (3 hours minimum/FACILITY) $234.00 minimum S P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) L A N PLAN CHECK FEE = 578.00/h^ur (8 hours minimum/FACILITY) = $624.00 minimum 5 R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) E P TANK LINING REPAIR FEE = 578.00/hour (3 hours mini mum/TANK) # TANK(s) X $234.00 = 5 A I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S R PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION - 578.00/hr I 5 I S C CONSULTATION FEE = 878.00/hr SAMPLING INSPECTION FEE = 578.00/hr 5 TOTAL DUE FOR OFFICE USE ONLY Jr.!.......:....:...!.........:!..r:.!............r.......n...i.i:.i....................r..r..xl...........................,........................:..x......_...._.......b........!I ..... ...... ..__.___.......-. _._._.,:.....:........� !r � SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED i it ii! l S I!:: .a it 1; :.......�u:x.;.+.v v:,r ......r,4:.n,nv:r...wn nrrri..rin.in,...nv:... e., .v:,vay...v..ra...n... v v .:x!r: nn!!:!::x::::a.v�..um,:....f.rl.nv...v.__LT,_..:..._...v........... 312T..1.!L.,s.J..l!!.J..vIJ ill'l..vv.:..i..Jal.!m..a....r.............1.1.v......v.....1.............r.:.......r.IJP.:::.-..,..Im.L....__..........,.r.r..,.!_rr:Iv..il.nll..:. .........._.... ..e.....i..__._.._ .::v:... ..,., .........._.................... ...................... ...... . .. .................... ........................................._...... .............. .::e. .r.�:�:v��ec. n v.. .:..-�:r��-v�:�:r-i :uFd:u�lJi.mrNiILJ.:. Jnn::m:::J:na!il:::L::::Lni!!:nJ:a:::::::::J,mdlixl!:!Inrv!WI:,!!!xxJ:::::::n:v:denJxnxc!m:n:cL!:cl=utnnb:IJ,I:b&=t!:u:J::::II!d!n!nnu::JJm4+:ri08LNu._..._._..W_LLIv..:vnJuv �..3..v.'�.n..:..,.u.r.d24!ri!"__F:_._ Fw 74 nip IPFViSFD 1-12.98) •