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` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> AMDERGROUND STORAGE TANK PROGRAM - FEE WORKS <br /> S FACILITY SITE NAME FACILITY TACT NAME <br /> I �� <br /> 'E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & 9 � M �k� PM <br /> CITY i' STATE ZIP CODE # of TANKS `9 ,{� <br /> A �!i 171 ICA 2-1Z at SITE 2 � 1 <br /> P <br /> P� APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L p� C <br /> C MAILING ADDRESS I APPLICANT PHONE # WITH AREA CODE <br /> Al <br /> N <br /> I�37 N. 1. L�lp <br /> T1 CITY STATEI ZIP CODE TYPE t AP A'Ll� <br /> (L. CI)k 5 (Closure, Installation, etc.) ,. <br /> " <br /> t4EW OrIN4 121SrSt4$EPo.5 TOTAL <br /> 1986 1987 1988 1989 i 1490 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX XXXX I XXXX $ XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX I XXXX I XXXX XXXX I XXXX 3 XXXXXXXX <br /> I <br /> Y) TANK FEE = 350.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1988 1989 1 1990 i 1991 11992 1993 11994 ` 1995 11996 1997 11998 <br /> F (multiply # by fee fo3r I 1 <br /> Al each year applicable) XXXX I XXXX XXXX I XXXX XXXX i <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX XXXX XXXX I XXXX (XXXX I I ( I I 13 <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 3 <br /> T <br /> Y # Tanks x $8.00 1988 through 1993 (S56) 1993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> Cj PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> Li <br /> OI CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = 3 <br /> Sr <br /> Ui TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. #(s) <br /> R <br /> Ei TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) I $234.00 minimum $ <br /> P� INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)+ TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 378.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> R1 REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br /> El <br /> Pi TANK LINING REPAIR FEE = 378.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> I1 TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = 378.00/hour (3 hours minimm/FACILITY) = $234.00 minimum <br /> MI TRANSFER FEE = $20.00 I I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I $ <br /> I � t <br /> S <br /> C CONSULTATION FEE _ $78.00/hr I SAMPLING INSPECTION FEE = 578.00/hr I f $ <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY <br /> _.............._.................._........................................... _........_.__._..._.............._._: µ :-::::.—::,a�:.:::::::::-__::::: .w.:__::::=: _ ::•::::_=-::::-w.-::::. 4::: ::::::::-::•M:-._:::- <br /> ....__...................................................................................................._ <br /> _......_ ::::::::::::::::::::-::::::::::::::::::-.-::•:—:.- -: -::::-•�—•:- •-: .—::::-::::: ;� - - .::::::Gam:.:::—:::-:as a :�----a ::-:::M:e_M...::.... <br /> SWEEPS # COMPUTER # I LOC CODE I DIST CODE ( AMOUNT RECEIVED CHECK #/CASH RECEIVED BY I DATE RECEIVED <br /> .._.._...___........_...�..._......._..._.._.. _ ...__........_��_r _._ :..1.:s :: M.�. .w :. - --- - - -- - <br /> EH 23 032 (REVISED 1-12-98) <br />