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TOTAL <br />1986 1987 1, 1988 i 1989 1 1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />Aj XXXX XXXX i XXXX XXXX I XXXX S XXXXXXXX <br />T! FACILITY PENALTY FECES ASSESSED (If ADpiicabte) XXXX XXXX j XXXX XXXX XXXX S XXXXXXXX <br />I <br />V; TANK FEE = $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br />Tanks = 1987 11988 1989 11990 1991 1992 1993 1994 1995 i 1996 j 1997 <br />F (multiply R by fee for <br />Ai eacn year apoiicable) ! XXXX 1 XXXX i XXXX XXXX IXXXX I ! I I S <br />C, <br />Ii TANK PENALTY FEES ASSESSED XXXX I XXXX XXXX I XXXX IXXXX S <br />L' <br />Ii STATE SURCHARGE FOR NEW FACILITIES ONLY = 518-50 �S <br />T' <br />v; R Tanks x 58.00 1988 through 1990 (S56) 1991 through 1996 (556)1 1997 <br />SURCHARGE FOR 1997 { XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br />CI PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) ` TANK I.D. '_(s) <br />L: <br />01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) i TANK(s) X 5234.00 = S <br />S, <br />UI TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D_ A(s) <br />R' <br />Ej TEMPORARY CLCSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br />i <br />P! INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections)I TANK I.D. R(s) <br />L <br />Al <br />NI PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br />MI TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S �y <br />Si 1 i ! ! ! <br />C! CONSULTATION FEE = 578.00/hr , I SAMPLING INSPECTION F=_E = 578.00/hr I S <br />TOTAL DUE S %I�t <br />FOR OFFICE USE ONLY <br />SwtcPS I COMPUTER S fI LOC CODE I DIST CODE I AMOUNT RECEIVED CHECK /CASH RECEIVED 3Y ) DATE RECEIVED <br />! S <br />EM 23 032 (RPVTRFn 5-77-07N <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />SI <br />FACILITY SITE NAM <br />ralwz <br />FACILITY CONTACT NAME <br />T <br />I <br />EI <br />I <br />FACILITY ADDRESS <br />. <br />( SITE PH AREA CODE <br />_- <br />/ <br />i —M <br />j <br />CITY <br />( iATE <br />ZIP CODE # of TANKS <br />AI <br />at SITE <br />P <br />P! <br />APPLICANT/BIL(I/INrW <br />APP ICA T CONTAIE& t <br />I I <br />Ci <br />MAILING ADDRES6 <br />APPLICANT PHONE 9 WITH AREA CODE <br />Al' <br />j s <br />623 3 <br />N' <br />T' <br />CITY <br />TAT-ci ZIP CODE TYPE of APPLICATION <br />keA* <br />) <br />I , (Closure, Instaiiation, etc.) <br />TOTAL <br />1986 1987 1, 1988 i 1989 1 1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />Aj XXXX XXXX i XXXX XXXX I XXXX S XXXXXXXX <br />T! FACILITY PENALTY FECES ASSESSED (If ADpiicabte) XXXX XXXX j XXXX XXXX XXXX S XXXXXXXX <br />I <br />V; TANK FEE = $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br />Tanks = 1987 11988 1989 11990 1991 1992 1993 1994 1995 i 1996 j 1997 <br />F (multiply R by fee for <br />Ai eacn year apoiicable) ! XXXX 1 XXXX i XXXX XXXX IXXXX I ! I I S <br />C, <br />Ii TANK PENALTY FEES ASSESSED XXXX I XXXX XXXX I XXXX IXXXX S <br />L' <br />Ii STATE SURCHARGE FOR NEW FACILITIES ONLY = 518-50 �S <br />T' <br />v; R Tanks x 58.00 1988 through 1990 (S56) 1991 through 1996 (556)1 1997 <br />SURCHARGE FOR 1997 { XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br />CI PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) ` TANK I.D. '_(s) <br />L: <br />01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) i TANK(s) X 5234.00 = S <br />S, <br />UI TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D_ A(s) <br />R' <br />Ej TEMPORARY CLCSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br />i <br />P! INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections)I TANK I.D. R(s) <br />L <br />Al <br />NI PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br />MI TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S �y <br />Si 1 i ! ! ! <br />C! CONSULTATION FEE = 578.00/hr , I SAMPLING INSPECTION F=_E = 578.00/hr I S <br />TOTAL DUE S %I�t <br />FOR OFFICE USE ONLY <br />SwtcPS I COMPUTER S fI LOC CODE I DIST CODE I AMOUNT RECEIVED CHECK /CASH RECEIVED 3Y ) DATE RECEIVED <br />! S <br />EM 23 032 (RPVTRFn 5-77-07N <br />