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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br />V" 'GROUND STORAGE TANK PROGRAM - FEE WORKSHEE <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />AMOUNT RECEIVED <br />CHECK #/CASH <br />RECEIVED BY <br />L <br />.................................... <br />E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />& <br />�I 64 S A -7/Q.,^' 5-�- <br />:-t:::::::::::::::::sssi's <br />S <br />-7STATE <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />CITY <br />ZIP CODE <br /># of TANKS ,� <br />Pe�A <br />Cy� <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />at SITE <br />P <br />APPLICANT/BILLING NAME 9/ZCO f�.?!!J•h�ctTs G'Gl7P/TiVcr �lG: <br />APPLICANT CONTACT NAME <br />L <br />7 <br />f <br />I <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />iPl/rt' 72,vo AiE 7� <br />�Zr ��/ 'Z5/ - 6-"-Z7Z_ <br />N <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />(Closure, Installation, etc.) <br />TOTAL <br />1986 1987 1988 1989 1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />A XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX <br />C <br />T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX <br />I <br />V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TA (After January 1, 1991) <br />E <br /># Tanks = 7i 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 ( ; 7 <br />F (multiply # by fee for <br />A each year applicable) XXXX XXXX XXXX XXXX XXXX $ <br />C <br />I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ LAv403S337 <br />L <br />I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T <br />Y # Tanks - x $56.00 1988 through 1990 1991 through 1996 <br />(Enter amount and year) <br />/?9 $ <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />AMOUNT RECEIVED <br />CHECK #/CASH <br />RECEIVED BY <br />L <br />.................................... <br />0 <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = $ <br />:::::::::.::..::::::::::: <br />:-t:::::::::::::::::sssi's <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum $ <br />Pi <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />AMOUNT RECEIVED <br />CHECK #/CASH <br />RECEIVED BY <br />L <br />.................................... <br />A <br />N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum X 1. <br />$ j j C�� <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />AMOUNT RECEIVED <br />CHECK #/CASH <br />RECEIVED BY <br />E <br />.................................... <br />P <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = $ <br />:::::::::.::..::::::::::: <br />:-t:::::::::::::::::sssi's <br />A <br />I <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) <br />= $234.00 minimum $ <br />R <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum $ <br />M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br />I <br />S <br />C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ <br />TOTAL DUE G $ <br />FOR OFFICE USE ONLY <br />SWEEPS # <br />COMPUTER # LOC CODE <br />DIST CODE <br />AMOUNT RECEIVED <br />CHECK #/CASH <br />RECEIVED BY <br />DATE RECEIVED <br />.................................... <br />:::::::::.::..::::::::::: <br />:-t:::::::::::::::::sssi's <br />6 <br />