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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME L FACILITY CONTACT NAME <br /> ric� 4 tnL•fl r �to J o 5� <br /> T <br /> FACILITY ADDRESS SITE PHONE it with AREA CODE <br /> CITY STATE ZIP CODE # of TANKS <br /> A �-2 at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> 1 <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N io yo q2.\ oil 4+4 9 <br /> T CITY STATE ZIP CODE TYPE of APPLICATION r-2 <br /> o. <br /> Alt <br /> C4 (A (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 S xxxxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx XXXX XXXX XXXX xxxx $ xxxxxxxx <br /> I <br /> V TANK FEE = 550 00/TANK (Prior to January 1,1991) 3170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX xxxx XXXX xxxx XXXX S <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx xxxx XXXX XXXX S <br /> L <br /> 1 STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 S <br /> T <br /> Y # Tanks x 58.00 1988 through 1993 (556) 1993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 XXxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxXxxxxxxxxxXxxxxx S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578 00/hour (3 hours minimum/TANK) # TANK(s)�_ X $234.00 = 3 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234 00 minimum 3 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK 1.0 9(s) <br /> - <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624 00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK i.D #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78 00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min /FACILITY) = SP-34 00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234 00 minimum S <br /> M TRANSFER FEE = S20 00 UNAUTHORIZED RELEASE EVALUATION = S7B 00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE = S78 00/hr SAMPLING INSPECTION FEE = S78 00/hr S <br /> TOTAL DUE t O O <br /> { OFFICE USE ONLY <br /> r : s— .. .»...»»m:r».. r.�.^»ry�— --_ __ s�r —__—r—s r—�rr____�__ _ ...n...____ _ __e�-sr- ..•—^•••...„'—r s r ——' <br /> ...s-. <br /> SWEEPS # COMPUTER # LOC CODE <br /> _»W DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED 14 <br /> =, S <br /> r—rpm n sr nrrr sr _r»sin rr — Jnr sr s s'�nr r—r—rrr ---s—rms �u»rrrr—r—ss-s——_rr _�___sr•_—r_r—.....» ws�s�r——r _ r.»rs—r—»r»�—'r—'7��'^ 'r" 'r r <br /> — =— <br /> ..........�r.:......�....._» <br /> EH 23 032 (REVISED 1-12-98) <br />