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SAN JOAQUIN COUNTY PUHLTC HEALTH SERVICES - ENVIRONMENTAL HEALTH 0IVSIO" <br /> y UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> c <br /> FACILITY SiTE NAME FACILITY CONTACT NAME <br /> .� --w -- <br /> E FACILITY ADDRESS SITE PHONE # with AREA C00 <br /> IMNT <br /> CITY STATE ZIP CODE <br /> // oTANKS <br /> atSiTEfJ�C�' RECEIVED <br /> P APPLICANI/BILLING ME APPLICANT CONTACT NAME JAN 1 1 1993 <br /> L 15AA4 E <br /> r, C NAILING ADDRESS APPLICANT PHONE # WITH AREA M8t.iC IWAOHI RERVIC <br /> A ENVIRONMENTAL HEALTH DI <br /> T CITY STATE ZIP CODE TYPE of APPLICATION �7 <br /> (Closure, Installation, etc.) REMO ORl{- <br /> - TOTAL <br /> 1986 1987 1988 1989 , 1990 <br /> ANNUAL. FACILITY FEE (Prior to Jenuary 9, 1991) r S100-00 ' — 5 <br /> A _ <br /> T FACILITY PENALTY FEES ASSESSED (if ApplicAble) XXXX~ XXXX <br /> 1 -- <br /> V TANK FEE = 550.00/1ANK (Prior to January 1,1991) 5170/LANK (After Jnnunry 1, 1991) <br /> No E <br /> Tenks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F tmuitiply fee for — <br /> A each year appi lcable) x <br /> C - — S <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX <br /> L <br /> I STATE SURCHARGE - 556.00 each YANK (Due every 5 years) See California N & S Code, Section 25287 <br /> T 1991 through 1996 <br /> T # r•�nnka x 'ISb.Do 1986 thrauph 1990 _ <br /> (Enter amount and year) s <br /> C PERMANENT CLOSURE (Removal or Authorized Closure in Place) TANK t.0. <br /> 1. <br /> # TANK(*) X $23Yi.OD n S rev <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimun/TANK) � 1, <br /> S - TANK I.D. #{s) <br /> u TEMPORARY CLOSURE (Pion Review & Inspections) <br /> .� R —. _ <br /> E TEMPORARY CLOSURE FEE a 578.00/hour (3 hours minimixti/TANK) # YANK(s) X 5234.00 5 <br /> P TRSTALLA110N PLAN CHECK (Plan Review & Construction inspections) TANK I.D. #(a)_ <br /> — <br /> L _.. - <br /> A = 5624.00 minim <br /> xx5 <br /> N PLAN CHECK FEE - 578.00/hour (8 hours minlnuil/FACILITY) <br /> I <br /> R REPAIR FEE (Workpton Review & Construction Inspections) TANK I.D. #(s), <br /> E # 1ANK(s) X $234.00 S <br /> P LANK LiNING REPAIR FEE = 578.00/hour (3 Hours minimum/TANK) <br /> A — 5 <br /> 1 TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br /> R - 423t�.00 mfnirlxm 5 <br /> PiPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br /> N TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION � 5"I 00/hr 5 <br /> - <br /> S _—_ / <br /> C CONSULTATION FEE 578.00/hr SAMPLING INSPECTION FEE = 578.00/lir 5 1 <br /> TOTAL DUE q C) a7 <br /> FOR OFFICE USE ONLY r .r rl l� xmxmm xiltmn?rale 1 nixl nlxlnn!xlsxmmi aii!mu!1.xnuirnmm!n!xm!auxnik!np?mill mg Mmumnt lrn?!n. imn nlmkulmxlllllpJl <br /> p( gp I k 1!ImilYl 1 it I fU.ixxn xlillll inliilpI. ..EIn4 i x i 1.11!!!!!i?!I!:??x?!!itEnU±!!•:r?'z'.'.'^ =n'1i <br /> •� IS: 1 I m�lx{{pp111U n 1 111mim1{Ilnlli11Mi1 Til��• I!s�i I m - I., ,f ..:: .!. 9' '�{ �':,�:�'p1 r:• ' .... <br /> : .�• „It!II?!.ha!!UI�!1n!mU!{!}LITH±!n!L1?!3U!L!L?!a!±!!i?I!?{.S !I."!!i;i•.i 1?t.°t"!! !:+..:::•'1?P.i!A?.:±i?!i!!I!lUx:.!dl1!!±±F.!?!!!:!is.._.._.-.1i!?!Inl:E?U?.aos.la: <br /> SWEEPS 0 COMPUTER (f LOC CODE DIST CODE AMOUNT RECEIVED CIIECK #/CASII RECEIVED 8Y OATE RECEIVED <br /> IM"IFITIRM, r n nl!I {i{{m{{s"{{ .E{i{?li�iil{ii{. 7nii{{ii#n`nn�vi{{{{{ i{i itrii?!i*!i��`liin°i{n.??ix rt{e"mn m;m`Itsi��m a! ixil!i �4!i{{ �i! i{{!!ai{{ <br /> y <br />