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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH OIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> 1,30 L- <br /> FACILITY ADDRESS SITE PHONE N with AREA CODE <br /> '2„-70 ) <br /> CITY STATE ZIP CODE 9ofITTANKS <br /> APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> ;L.-c' �-.�c� rid�•1 I <br /> MAILING ADDRESS APPLICANT PHONE 9 WITH AREA MOE <br /> 2 Ss;iYC7 l�.n i✓ - 2.o L. 1 to Zt-!L.4 y <br /> CITY STATE ZIP CODE TYPE of APPLICATIONI. � <br /> C 4, , ICJG--7,4-2_ (Closure, Instal Lation, etc.) <br /> " TOTAL <br /> i 1 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1491) = 5100.00 1986 1987 1988 1989 1990 <br /> XXXX XXXX =cx I S <br /> FACILITY PENALTY FEES ASSESSED (If Applicable) P XXXX I X= 1 xxxx P S <br /> TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> ( ranks = E19#1816 1988 11989 1990 1991 1992 ( 1493 11994 1 1945 ( 1996 <br /> F (multiply ooyy fee for <br /> A each year appplicable) XXXX I � S <br /> I TANK PENALTY FEES ASSESSED I xx ( XXXx P I P i 5 <br /> STATE SURCHARGE a 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> f x Tanks_3 x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> -. 16 1 S <br /> PERMANENT CLOSURE emoova or Authorized Closure-in-Place) TANK I.D. 9(s) <br /> ;1 CLOSURE FEE = S78.00/hour (3 hairs minimum/TANK) 9 TANK(s) X <br /> UI TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> El TEMPORARY CLOSURE FEE = S78.00/hoar (3 hags minimum/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Ptah Review & Construction Inspeetions)I TANK I.D. S(s) �� w <br /> L <br /> N PIAN CHECK FEE = S78.00/hair (8 hags minimam/FACILITY) : $624100 minimum S ef( - — <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. 'S(S) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hoar (3 hams minimum/TANK) S TANK(s) X 5234.00 = S <br /> _ A <br /> I TANK RETROFIT REPAIR FEE _ S78.00/hoar (3 hours min./FACILITY) = S234.00 minimum S <br /> A <br /> 1 PIPING REPAIR FEE = S78.00/hoar (3 hams minimum/FACILITY) = S234.00 minimum S <br /> M TRANSFER FEE = S20.00 ' UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 1 I S <br /> i <br /> C CONSULTATION FEE = S78.00/hr I I SAMPLING INSPECTION FEE = S78.00/hr i 1 S <br /> FDR OFF tIa^ aI <br /> 6? Toru DUE 5 <br /> SWEEPS ICOMPUTERLUC ccceI0 EI I EREEK 97CASH FtECEIV-0 lynA R av <br /> EH 23 032 (REVISED 4-29-94) Page 11 <br /> Pd . <br /> ? 7/ 7 <br />