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S <br />I <br />E <br />I <br />SAN JOAauIN COUNTY PUBLIC HEALTH SERVICES - ENVIR <br />onmcvrMMM STORAGE TANK PROGRAM( - FEE WORKSHEET <br />11 C?e . <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />C 13 <br />1988 <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />z oS r--N;rA0nIA3 L:r-De. <br />I z0q-X1700-6 55 <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />at SITE <br />S TOC Tb/J <br />as XXXXXXXXXXXXX <br />852.07 <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME r <br />C-4 &rwIEt.� <br />onl a Pm <br />I E Lc: <br />APPLICANT PHONE # WITH AREA CODE <br />MAILING ADDRESS <br />z — oDz <br />CITY <br />�ST�ATTFZIP <br />CODE TYPE of APPLICATIONKn�3'0gO <br />installation, etc.) <br />FEES ASSESSED Cif Applicable) <br />T FACILITY PENALTY <br />(Closure, PRlp— <br />TILT l � <br />C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) <br />LI # TANK(s) X 5234,00 = S <br />0 CLOSURE FEE = 578.001hour (3 hours minimum/TANK) <br />S ITANK I.D. #(s) <br />U TEMPORARY CLOSURE (Plan Review & Inspections) <br />RS <br />E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)IJANK 1.0. #(s) <br />L <br />A= 5624.00 minimum S <br />N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br />R REPAIR FEE (Workplan Review & Construction Inspections) ( TANK I.D. #(s) <br />E X 5234.Otl = S <br />P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) <br />A5 23},00 <br />T TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum <br />R = 5234.00 minimum S <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />N TRANSFER FEE = 520.00 I UNAUTHORIZED RELEASE EVALUATION = 378.00/hr <br />I <br />SS78.Otl/hr S <br />C CONSULTATION FEE = S78.Otl/hr SAMPLING INSPECTION FEE ,s •.• <br />TOTAL DUE L-2 I0 <br />FOR OFFICE USE ONLY <br />SWEEPS # I COMPUTER # I LOC CODE I GIST CODE I AMOUNT RECEIVED I CHECK #/CASH I RECEIVED BY I DATE RECEIVED <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />XXXX <br />XXXX <br />XXXX <br />X)X( <br />XXXX <br />as XXXXXXXXXXXXX <br />A <br />XXXX <br />XXXX <br />XXXX <br />S XXXXXXXXX)=X <br />FEES ASSESSED Cif Applicable) <br />T FACILITY PENALTY <br />I <br />V TANK FEE = 550.001TANK (Prior to January 1,1991) <br />5170/TANK (Atter January 1, 1991) <br />E <br />1986 <br />1987 <br />1988 <br />1989 11990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />0 Tanks = <br />S <br />F (multiply At by fee for <br />A each year applicable) <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX I XXXX <br />I <br />S <br />C <br />I TANK PENALTY FEES ASSESSED <br />L <br />I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 2528 <br />T1488 <br />T # Tanks X S56.00 <br />through 1990 <br />1991 throygh 1996 <br />I <br />I5 <br />(Enter amount and year) <br />C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) <br />LI # TANK(s) X 5234,00 = S <br />0 CLOSURE FEE = 578.001hour (3 hours minimum/TANK) <br />S ITANK I.D. #(s) <br />U TEMPORARY CLOSURE (Plan Review & Inspections) <br />RS <br />E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)IJANK 1.0. #(s) <br />L <br />A= 5624.00 minimum S <br />N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br />R REPAIR FEE (Workplan Review & Construction Inspections) ( TANK I.D. #(s) <br />E X 5234.Otl = S <br />P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) <br />A5 23},00 <br />T TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum <br />R = 5234.00 minimum S <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />N TRANSFER FEE = 520.00 I UNAUTHORIZED RELEASE EVALUATION = 378.00/hr <br />I <br />SS78.Otl/hr S <br />C CONSULTATION FEE = S78.Otl/hr SAMPLING INSPECTION FEE ,s •.• <br />TOTAL DUE L-2 I0 <br />FOR OFFICE USE ONLY <br />SWEEPS # I COMPUTER # I LOC CODE I GIST CODE I AMOUNT RECEIVED I CHECK #/CASH I RECEIVED BY I DATE RECEIVED <br />