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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHE <br /> S! FACILITY SITE NAMEW 11 FACILITY C ACT NAME <br /> T aL.�. T454 <br /> E FACILITY ADDRESS N <br /> SITE PHONE # with AREA CODE <br /> ROrdCITY (���t82.- 78 <br /> A <br /> ��,P STATE ZIP COOS # of TANKS <br /> P CA' g533o at SITE <br /> P /BILLING NAME 23 <br /> APPLICANT CONTACT NAME <br /> L <br /> I T r3 p.R <br /> CDDRESS <br /> A ® APPLICANT PHONE # WITH AREA CODE <br /> N 44 - <br /> T ffl le <br /> STATE ZIP CODE TYPE of APPLICATION <br /> 1A 5-�$-� (Closure, Installation, etc. <br /> TOTAL <br /> A "NU-.:. FACILITY FEE (Prior to January 1, 1991) = S100.00 1986 1487 1988 1989 1990 <br /> C XXXX XXXX XXXX XXXX XXXX S XXXXXXXX <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX <br /> V E (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> 9 Tanks = _ 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 <br /> (multiply # by fee for <br /> 1 each year applicable) XXXX XXXX XXXX XXXX XXXX <br /> 5 <br /> TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX <br /> STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 <br /> S <br /> # Tank;,' , x S8.00 1988 through 1993 (S56) 1993 through 1997 (556) 1998 <br /> NRCHARGE FOR 1998 XXXxxXXXxxxxXXXXXXXXXXXXXXX xxxxxxxXXX XXX V/ S <br /> ._RMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.O. #(s) <br /> CLOSURE FEE = S78.00/hour (3 hours minimWTANK) # TANK(s) X S234.00 <br /> = <br /> �_ <br /> TEMPORARY CLOSURE (Plan Review b Inspections) TANK I.D. #(s) <br /> TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimmVFACILITY) 5234.00 minimum <br /> S _ <br /> INSTALLATION PLAN CHECK (Plan Review b Construction Inspections) TANK I.D. #(s) <br /> PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br /> 5 .C3U <br /> REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(Eminim:= <br /> 5234.00 <br /> S - <br /> TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY <br /> S234 5 -� <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = 5234 <br /> TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br /> 5 � <br /> CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br /> :E UOLY TOTAL DUE <br /> t•,_._SEu.wlu:,NwuFMINE udfuiiiuiiww'iSiFSui_:ciuiu»;•.._.._...._........r•:r:•.••. .•... •••.._••:=•...•••.._.....:....:»...r»:::::.:..•.-enure-err_,. s'V.K/ <br /> U.1 <br /> COMPUTER �_:::.^.•••�_»�•.:-;-:•;.:_.»:•••:••:•::�I�^�nnr° <br /> WEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED TE RECEIVED <br /> bt[uis:wci{"""u.'f"'...;...�...r_••,::,. :¢::.�.;. ...;:.:. r q°„m,.8;ryeilnL.l.tuue._t QQItt<•e�m"1'!^"t!!I!'!II"m �p <br /> •..:...,. ....... .tlk+s4a...i,.+.Htu,3ura:iraa:m::i:�jmi:.r.:•::r...r.::...::z;:.... •.0.� ._...�•n*fi'.�7fflgr!!p UpWllllSlA — I,IWRLL Iq <br /> .... w .wt•.:Inc:::rc:urar. •81!!ipii •:WifMUMMM1U(Ululil' ''ffluu <br /> S 032 (REVISED 1-12-98) <br />