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9-23-1998 3:15PM FROM P'4 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />T <br />FACILITY lITE NAME <br />Gt/E1/12a�.! 5'%�/nil 9 3232 <br />FACILITY CONTACT NAME <br />1Q,c.o Go.�i�'•�-ss <br />E <br />FACILITY ADDRESS <br />860&0 Lvwee 69'efoq lFivro J80 <br />SITE PHONE # with AREA CODE <br />2Q9 - •H77_e2 <br />& <br />P <br />CITY <br />s�c�G/G-rorl/ <br />STATE <br />ZIP CODE <br />s21C7 <br />0 oStTANKS h <br />J <br />P{ <br />I <br />- <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />,nam r-�sr <br />C <br />N <br />MAILING ADDRESS ,p-� <br />10 � �J. ti�7>� <br />APPLICANT PHONE # UITH AVEODE <br />yl�g S J.s <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE ofAP pION /�Vl. �Vpri7 <br />(Closure,llation, etc.) <br />TOTAL DUE I S -.1291J. 00 <br />FOR OFFICE USE ONLY <br />_._...... ..................: c...euu...»............_........._......._.____._r.:raxuuq,nuor p—••:_.._....__...........:.....:...:..a. mnf{!f!HtlitiJ!1JI!Jl!!J!lE4ili;!IIGI!!!::[IEF.'r.SPF <br />,.......... ......... ... .IOIRJJdi�lfu.u6aa...:_�:•::.•=_r.:r::r:xS:::rd:•1:,rn: <br />SWEEPS # COMPUTER # ` LOC CODE DIST CODE I AMOUNT RECEIVED ( CHECK #/CASH I RECEIVED 6Y i DATE RECEIVED <br />S <br />v <br />tvtAL <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />A <br />1986 198 1988 <br />Af <br />1989 <br />1990 <br />X XX Xxxx <br />XXXX <br />I XXxx <br />5 <br />XXxxxxxx <br />C <br />TI FACILITY PENALTY FEES ASSESSED (if Applicable) <br />X XX XXX <br />XXXX <br />XXXX <br />$ <br />XXXXXXXX <br />I <br />Y TANK FEE - $50.001TANK (Prior to January 1,1991) <br />5170 T K ft30 January 1, 1991) <br />E <br />9 Tanks = <br />F (multiply # by fee for <br />A each year applicable) <br />1988 <br />1989 <br />1990 <br />1991 <br />1992 <br />1993 1994 <br />5 <br />I 1996 <br />1 1997 <br />1998 <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />5 <br />C' <br />I: TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />U <br />$ <br />L <br />I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 <br />S <br />T <br />Y # Tanks x $8.00 <br />SURCHARGE FOR 1998 <br />1988 throng 56) <br />1993 through 1997 (S56) <br />1998 <br />XXXXXXXXX X XXXXXX XXXXXXXXXXXXXXXXXXXXXXX <br />S <br />C1 PERMANENT CLOSURE (Removal or Authors Cl s in-Piaee) <br />TANK I.D. #(s) <br />L' <br />0 CLOSURE FEE = S78-00/hour (3 hours inf / NK) <br /># TANK(s)�I X $234.00 = <br />g <br />P�1 <br />S <br />UI TEMPORARY CLOSURE (Plan Review & Ins S) <br />TANK I.D. #(s) <br />R <br />E TEMPORARY CLOSURE FEE = $78.00/hour (3)(ours minim FACILITY) <br />$234.00 minimum <br />$ <br />P INSTALLATION PLAN CHECK (Plan Revi w & Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE = $78.00/hour hours minimum/FACILITY) <br />- $624.00 minimum <br />S <br />Rl REPAIR FEE (Workplan Rev' Construction Inspections) <br />TANK 1.D. #(s) <br />E <br />P TANK LINING REPAIR FE = S78.00/hour (3 hours minimum/TANK) <br />I # TANK(&) X 5234.00 = <br />$ <br />A <br />1 TANK RETROFIT REPAIR/FEE = S78.00/hour (3 hours min./FACILITY) <br />= $234.00 minimum <br />5 <br />A J�11-T <br />R <br />PIPING REPAIR FEE 3 $78.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum <br />S <br />N TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />$ <br />s <br />C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br />= s78.00/hr <br />S <br />TOTAL DUE I S -.1291J. 00 <br />FOR OFFICE USE ONLY <br />_._...... ..................: c...euu...»............_........._......._.____._r.:raxuuq,nuor p—••:_.._....__...........:.....:...:..a. mnf{!f!HtlitiJ!1JI!Jl!!J!lE4ili;!IIGI!!!::[IEF.'r.SPF <br />,.......... ......... ... .IOIRJJdi�lfu.u6aa...:_�:•::.•=_r.:r::r:xS:::rd:•1:,rn: <br />SWEEPS # COMPUTER # ` LOC CODE DIST CODE I AMOUNT RECEIVED ( CHECK #/CASH I RECEIVED 6Y i DATE RECEIVED <br />S <br />