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SAN JOAQUIN COUN401BLIC HEALTH SERVICES - ENVIRONMENTAL HEAL:T'IVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> 1 -7Co rill l i�11 J1 <br /> T <br /> E FACILITY ADDRESS 14&1 Hammer � .�rle, SITE PHONE # with AREA CODE <br /> & l�1 <br /> CITY STATE ZIP CODE # of TANKS <br /> A 5toL', 'fA I q's at SITE 4- <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> H - KZ4-4 /" hemi <br /> C MAILING ADDRESS ,1 �� APPLICANT PHONE # WITH AREA CODE <br /> N 13 0 [�11'Iloj fi{ 510) (fid' 6�-Cx) <br /> T CITY ZIP CODE TYPE of APPLICATION <br /> /o�^wrd GA d452L) (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX <br /> I <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) t&V 110 4L/ <br /> E 7 <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 19$7 <br /> F (multiply # fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX XXXX $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX XXXX $ <br /> L <br /> I STATE SURCHARGE _ f� <br /> T <br /> Y # Tanks x $8.00 1988 through 1990 1991 through 1996 1997 <br /> (Enter amint and year) <br /> XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXX $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) " 4 4 <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum X 1.5 ( �Q�I� $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr $ <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY <br /> ...................................._......_... .......__..._....._._.__...__.._; <br /> SWEEPS # I COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> $ _ <br /> ::-::::::• _ ........- __ .... _ <br /> EH 23 032 (REVISED 4-24-97) <br />