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5-26-1998 1 :Q8PM FP,O�'', P- Q <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIROIOENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAN - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I _ t_.C . - C\2 <br /> T — - 1 <br /> Eli FACILITY ADO SS SITE PHONE # ui;h AREA E <br /> 1 CITY STATE ZIP CODE # of TANKS <br /> A \ <br /> � -; at SITE .3 <br /> PI APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> LE'LV`C 5 —�mS �C . 1 0 f-_ %rte U.�C� i <br /> C MAILING ADDRESS I APPLICANT PHONE # WITH AREA CODE <br /> " <br /> I '71-�9 <br /> CITY STATE ZIP CODE TYPE Of APPLICATION <br /> /�,,� i <br /> I 11 SC:S'L� q5� I oZ (Closure, Instaltation, etc.) <br /> TOTAL <br /> 1 1 " <br /> ANNUAL FACILITY FEE tPfiar to January 1, 1991) 5100.00 1986 1987 1988 19$9 1990 <br /> A XXXX XXXX XXXX i XXXX XXXX S XXXXXXXx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applipeble) ' XXXX + <br /> I XXXX i 100(X XXXX I XXXX S XXXXXXXX <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 2 Tanks = 1987 1988 1989 1990 1991 1992 M 1993 11994 1 1995 1996 11997 <br /> F (mu[tipty # by fee for <br /> A each year applicable) XXXX XXXX XXXx XXXX IXXXX 1 1 j + S <br /> C 1 <br /> 11 TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX IXXXX f I f S <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY a 518.50 I5 <br /> T <br /> Y # Tanks x 58.00 1988 through 1990 (S56) 1991 through 1996 CS56) 1997 <br /> SURCHARGE FOR 1997 xXXXXXXXXxXXXxxxxxxxxxx)D(X)I XXX)O0O000U(XXXXXXXXXXXx 5 <br /> Ci PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) I TANK I.D. $(s) <br /> L <br /> 0CLOSURE FEE 578.00/hour C3 hours minimus/TANK) I # TANKts) X 523E.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I_D. #(3) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.001hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br /> P INSTALLATION PIAN CHECK (Plan Review 8 Comtrucrion Inspections) TANK I.D. x(s) <br /> L <br /> A, <br /> N PLAN CHECK FEE a S78.00/haur (8 hours minia"WFACILITY) ■ S624.00 minimum S <br /> Rl REPAIR FEE (Workplan Review i Construction Inspections) TANK I.O. 0(s) <br /> E <br /> P TANK LINING REPAIR FEF s 578.00/hour (3 hours m)nimus/TANK) it TANK(s) X s234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) e SM.00 annimiun $ <br /> R <br /> PIPING REPAIR FEE 578.00/hour (3 hours minimum/FACILITY) = 523E_00 minimum 5 <br /> Ni TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I-Y 1(5—' _ S - <br /> S <br /> Cj CONSULTATION FEE = 578.00/hr I , SAMPLING INSPECTION FEE = 578.00/hr 5 <br /> TOTAL DUE 5 <br /> FOR OFFICE USE ONLY <br /> SWEEPS # I COMPUTER # I LOC CODE I DIST CODE AMOUNT RECEIVED j CNECX #/GSM RECEIVED 6Y I DATE RECEIVED _I <br /> r _ <br /> r <br /> _.'!L'IC_'ll .Ilnlli/ri::i:::._—.:!!1174YIII�...mill-:.�u:::�_�—X1.•0:_.._.�ti�:�l::l . �i;u�_._�___—.�7t'.Ml. . __:.'_._J <br />