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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> N'^ GRGUNO STORAGE TANK PROGRAM - FEE WORKSHE <br /> S FACILITY SITE NAMEWr FACILITY CON.n'T NAME <br /> I 5 land -eleien More 217510 <br /> T <br /> E FACILITY ADDRESS SITE PHONE it with AREA CODE <br /> 53 E . `(o5erni�2 <br /> CITY STATE ZIP CODE # of TANKS <br /> A M2�1teos CA Olay at SITE 2. (new) <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L RNL Desi n &row / Inc Zai Q &iznw) <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A (o5b Howes Avenue , VV504- (alto) co4lo-400 <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITY <br /> Sacramento Ga 95825 (Closure, Installation, etc.) ins la ion <br /> TOTAL <br /> 1986 1987 1988 1989 1 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 <br /> XXXX XXXX %%XX X%XX XXXX S XXXXXXXX <br /> A <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXX% XXXX X%%X XXXX X%XX S XXXXXXXX <br /> 1 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks —z-- 7987 1988 1989 1990 7991 7992 1993 1994 1995 1996 1997 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX X%XX %XXX XXX% XXXX S 'Lt7 <br /> C I S <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX %XXX %XXX XXX% <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = 518.50 j5 <br /> T <br /> Y # Tanks 2. x $8.00 1988 through 1990 (856) 1991 through 1996 ($56) 1997 <br /> SURCHARGE FOR 1997 XXXXXXX%%XXXXXXXXXXX%XXXXXX XXXXXXXXXXXX%XXXXXXXXXX <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> 00 <br /> L # TANK(s)_ X 5234.00 = S <br /> 0 CLOSURE FEE = 578. /hour (3 hours minimum/TANK) <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R g <br /> $234.00 minimum <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br /> E <br /> TALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> N CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br /> ' R REPAIR FEE (Workp(an Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours mini mum/TANK) # TANK(s) % $234.00 = 5 <br /> A S <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum <br /> R 5 <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br /> N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S 5 <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br /> TOTAL DUE $ 900-00 <br /> FOR OFFICE USE ONLY —.._..... _.__._ ..._........_.._ �. .:.:_:-.�s.--�-_..= y-,:;._ ,__—_,:::::-:-.-__:::=_ <br /> ........................................._ .._.___::._._.........�., ...__..._.,:....:.,.,.._.__ xx..:,, -,..__........_� ,........._.___ ........_.__._...,........._..._............._.......,._._...._...._................:..:....._....... <br /> ..,..._...:................... ..............._................._,:::::::::::,...,:�::::-.__...:!,,,,:,,::::,:,,: .__._: M„_.:=_:::::-::::,::��::: ,:�c:wee_.,:,::__:!!!:!��.Y::-:,,.�___, :___._...__.,:_._..... <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED 8Y DATE RECEIVED i <br /> ii <br /> _�-M <br /> EH 23 032 (REVISED 5-27-97) <br />