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SAN JOAQ1UIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T m LI _ <br /> FACILITY ADDRESS SITE PHO E # with AREA CODE <br /> 2- � 2 <br /> CITY `` STATE ZIP CODE # of TANKS <br /> A C )C V a . g�_(:) at SITE I t 0 <br /> P ` <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> CtILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A Ar— <br /> � �Q� <br /> N <br /> T CITY STATE ZIP CODE [TYPE of APPLICATION 7/Uk— ,e4& <br /> _ Sr2ca� (Closure, Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ ;104.00 1986 1987 1988 1989 1990 <br /> A $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXxx xxxx 5 <br /> I <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) 1170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = T— 1986 1987 1 1988 1989 1990 1991 1 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) a <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX $ <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> r <br /> Y # ranks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> Z-' <br /> $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = ;78.00/hour (3 hours minimum/TANK) # TANK(s)_Z__ X $234.00 = S ,/ <br /> S _ <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minima/TANK) # TANK(s) X $234.00 - S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK l.D. #(s) <br /> L <br /> A <br /> H PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ <br /> A <br /> 1 TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = ;234.00 minimum 5 <br /> R <br /> PIPING REPAIR FEE _ ;78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum ; <br /> H TRANSFER FEE _ ;20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr t <br /> I <br /> S <br /> C CONSULTATION FEE _ ;78.00/hr SAMPLING INSPECTION FEE = $78.00/hr 5 <br /> TOTAL DUE <br /> �d OFFICE USE ONLY <br /> -:.......................:............r.:::::::::::::n::::e::am;:u::;r.:u::w:::::;::::::::an::::[:i.•??!! .......................... s..........:. -.... _ ..... <br /> .........................:..::.......w.:3.�s....,..........:......_...s,.................s.»v..L......u..s...-... : .u..,.._:n....;. .... ......r..x. .:ssss.m <br /> ...................................... <br /> !En..............e..................a.:i.....:»_....l.._s::433t.w... :I I Lnnu:.ds..:..J:!_.u7sifiHlUllllllt4ssh:..tu..»...1....slLWei e_ss6:u.n.u.Lus:l3t{!�lfu-W.IwGtt:::»;•�• ::G:»::uf:::�»:u:LJ1Il!!llLn6sILilWLiWl3uluif33HWIILILILIIu:sas:u::u••,ss,liuui�lidil€!Fiiii?iliE8efi38iiiiiEFii!iiliiu�{uullig <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED H /CASH RECEIVED 8Y DATE RECEIVED {9 <br /> i€ 1� <br /> r ,a <br /> r .:::.:......._ <br /> .........:::....................................... 13 <br /> ........_.......:,:..:......._.......................L......._....__........_..,. ....... ...•,,,.E.E...ii.!.!l.....!!,"!!!!!Ii:?'!! sse�I: s r us.:v.n.,us uu;:m,;.a;uusss :a:n s-u:u :.n <br /> .................... _•.!i i! a: .t.........».....l........._._.._....!i!!.ldl...LIIt1...1.ILl...III!!!!Ilil l ; : •sr.8 <br /> ...r ...s.....:::::::rros:r::,,t-:u�:ss s:s:•r.:::r-::o^.:........... .........._... .......i..,». ..... ......,_..... ...„..».. .41.lL»i.......1'.�[}II:-:II:.:L....ILfllh...N <br /> r::•.•••..L..„.s.s....a.�.h:....v....i....s:»..-ss...ss.Wut:�s_ss!??kII:IIs;Es:;•t,#x:£a€!i!::sss?€sn:$s1s[s£?itis:Ft'.aWifls!B::!dac;�;:;c.l;t:1::l::�sss:ct?YII�I!!aiRiiiiiilliliiAGiLi'•Jiiileii:ililiili:.liiFliiiiFllaiEiGiGiiiiuiillill'� <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />