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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> GROUND STORAGE TANK PROGRAM - FEE WORKSHEE` <br /> S FACILITY SITE NAME I FACILITY COAD CT NAME <br /> I -1-- ) =• --.p 2Z t Z <br /> E FACILITY ADDRESS I SITE PHONE ;* with AREA CODE <br /> & <br /> CITY STATEI ZIP CODE I # of TANKS <br /> A �-� Ga l+ at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L l L_ =Y� La✓ L�-71 4-4�) l yl-�=•-, <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE * WITH AREA CODE <br /> " <br /> N <br /> TIT <br /> Y STATE 14ZIP <br /> CODE TYPE of APPSYy, (Closure tnstatlot• etc.) <br /> TOTAL <br /> ' 1986 11987 1988 � t989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX ( XXXX I XXXX i XXXX I XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX I XXXX I XXXX I XXXX I XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) <br /> Tanks = 11987 1988 11989 1 1990 11991 11992 11993 11994 11995 11996 1997 �^� <br /> F (multiply 4 by fee for <br /> A each year applicable) XXXX I XXXX I XXXX I XXxX (XXXX I I I I I S 5-1.0 <br /> L I I ( I I I I I I rN✓. ��� <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX S <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = 518.50 IS <br /> T <br /> Y 4 Tanks x 58.00 I 1988 through 1990 ($56) 1991 through 1996 (S56)� 1997 O 0 <br /> SURCHARGE FOR 1997 xxxxxxxXXXXXXXXXXXXXXXxxxxx xxxxxxxxxxxxxxXxXxxxxxx 5 <br /> C PERMANENT CLOSURE (Removal 'or Authorized Ctosure-in-Place) I TANK I.D. 41(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I 0 TANK(s) X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. (s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. ;*(s) Te�v. <br /> L <br /> A PWS <br /> N PLAN CHECK FE=_ = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> pVer'�G� <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. 'Zks) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE = $20.00I I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr i S <br /> I <br /> S1 1 1 1 1 <br /> C1 CONSULTATICH FEE = 578.00/hr I I SAMPLING INSPECTION FEE = 578.00/hr ( S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> --- -- - - -- _ -- 7�; <br /> -•- :_------=:= : =:�-:.•_:::::.:____.—:•::--_.__.�.::-•ter..•�•.—:::_=�::�-�._.-.--:�_::.—w::•:._____._.___==-�:.—-_=_:--�..__mow.;;::::::_.�_._._..._.._,.. __..; <br /> SWEEPS 4 COMPUTER 9 I LOC CODE I DIST CODE I AMOUNT RECEIVED + CHECK $/CASH I RECEIVED 3Y I DATE RECEIVED <br /> : <br /> EH 23 032 (REVISED 5-27-97) 0 <br />