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SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICS - ENVIRCNMEVTAL HEALTH OIVSIC9 <br />gftERGRwo STORA E TANK PROGRAM - rcc WORKSHEft <br />FAC:LlT SITE NAM" <br />II <br />FACILITCMWAC,- Y CACT NAME <br />CLOSURE <br />��4t/ <br />rFACILITY AGGRESS <br />t, <br />SITE ?HCNE -1 'with AREA CODE<� <br />CITY r+ STALE <br />2(P C(bE I a of RANKS <br />5(TE <br />1 � G <br />J Ir <br />a[ <br />i <br />' APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />MAILING ADORESS <br />` l3 1i�cQ 9.a 3 <br />APPLICANT PHONE 9 WITH AREA CODE <br />UI <br />TEMPORARY <br />t <br />rl CIT. -t) <br />ii <br />ZIP ODES <br />CI?�. p(Closure, <br />TYPE or APPLICATION <br />Installation, <br />��� � <br />A <br />ecc.) <br />TOTAL <br />CI <br />' <br />CLOSURE <br />(Removal or Authorized Closure- in-Ptace) <br />I TANK (.J. =(s) <br />1986 i 1987 11988 11989 <br />11990 <br />7ANK(S1 _ X 5234.00 = 15 <br />: TANK(s) _ X 5234.00 = <br />S' <br />ANNUAL FACILITY FEE (Prior <br />t0 January 1, 1991) = 5100.00 <br />= 3234.00 minim . I S <br />R <br />UI <br />TEMPORARY <br />CLOSURE <br />(Plan .Review 3 insoec:iors) <br />TANK C.O. 3(s) <br />R <br />A <br />E, <br />TEMPORARY <br />CLOSURE <br />I %XXX I XXXX � XXXX <br />%XXX I XX%X <br />.5 <br />%XXXXXXX <br />C <br />Tj <br />FACILITY PENALTY FEES ASSESSED ([` Applicable) <br />I XXXX XXXX I XXXX I <br />XXXX I XXXX <br />5 <br />XXX%XX%X <br />VI <br />TANK FEE = S50.00/TANK <br />(Prior to January 1,1991) <br />5170/TANK (After January <br />1, 1991) <br />�L1 <br />1 <br />cTanks <br />= <br />1988 1989 1990 <br />1991 <br />11992 <br />11993 11994 11995 11996 11997 <br />I43' <br />4?jW <br />U-4 <br />F <br />A <br />(multip(y by Ree for <br />each year applicable) <br />I xxxx XXXX xnx <br />I XXXX <br />%XXX <br />ly' Ih�I1-1O IVID <br />v <br />C' <br />l <br />TANK PENALTY FEES ASSESSED <br />XXXX I XXXX I XXXX <br />XXXX <br />XXXX <br />I)<x X,."x I 10 0 <br />b <br />'` <br />•�p) <br />b)'SQ0 <br />L <br />[ <br />STATE SURCHARGE FOR NE'J FACILITIES ONLY=- I000 <br />Z <br />g•q <br />a� <br />T <br />53.00 <br />1988 thrcugh 1993 <br />(S56) <br />I 1993 through 1997 (S56)I <br />` <br />T <br />Tanks x <br />SURCHARGE FOR 'iclon <br />I xxxxxxxXXXX%%XXXXXXXXXxxxxx <br />I XXXXXXXX%XXXXXXXX%XXX%x <br />CI <br />PERMANENT <br />CLOSURE <br />(Removal or Authorized Closure- in-Ptace) <br />I TANK (.J. =(s) <br />L <br />01 <br />CLOSURE FEE = S78.00/hour (3 hours minimm/TANK) <br />7ANK(S1 _ X 5234.00 = 15 <br />: TANK(s) _ X 5234.00 = <br />S' <br />A <br />[ <br />TANK RETROFIT REPAIR FEE = 378.00/hour (3 hours min./FACILITY) <br />= 3234.00 minim . I S <br />R <br />UI <br />TEMPORARY <br />CLOSURE <br />(Plan .Review 3 insoec:iors) <br />TANK C.O. 3(s) <br />R <br />E, <br />TEMPORARY <br />CLOSURE <br />FEE = S78.00/hour (3 hours minimum/FACILITY) <br />3234.00 mini mm S <br />PI <br />L <br />INSTALLATION PLAN CHECK (Plan Review S Construction Inspe^_:ians)I TANK I.G. :(s) <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 mi nimm i <br />RI <br />REPAIR FEE (Warkplan Review 3 Construction Inspections) <br />TANK i.O. �'(s) <br />E <br />P <br />TANK L[41NG REPAIR FEE = 378.00/hour (3 hours minimum/TANK) <br />: TANK(s) _ X 5234.00 = <br />15 <br />A <br />[ <br />TANK RETROFIT REPAIR FEE = 378.00/hour (3 hours min./FACILITY) <br />= 3234.00 minim . I S <br />R <br />PIPING REPAIR FEE = 378-04/hour (3 hours minimum/FACILITY) <br />= 3234.00 minimum , S <br />MI TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I I S <br />II <br />Cl CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr <br />TOTAL DUE I S <br />FOR OFFICE USE ONLY <br />SW'E °SI COMPUTER S LCC CCOE GIST CCCE I AMOUNT RECEIVED CHECK +'/USM I .RECEIVED BY DATE RECEIVED <br />S I I <br />EH 23 032 (REVISED 1-12-98) . <br />