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SAN JOAQUIN COUa,Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL HIGH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE 61ORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> TCircle K F2cildy # 301205 <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> s 70 rid rive <br /> CITY STATE ZIP CODE # of TANKS <br /> P <br /> Laf�ro 415-33C at SITE <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I RHt- Desi n ro Inc. 7-2fqs &ianino Pro' • Gcorj. <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> " �!D Willow Pass Rd . Sure X120 <br /> ( Id� Oq '<o300 <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> GoneoYd 6A 94520 (Closure, Installation, etc.) 2ZMCm /21 <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1986 1987 1988 1989 1990 <br /> A XXXX XXXX xxxx XXXX xxxx $ XXXX%xxX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx XXXX XXX% XXXX XXXX S xxxxxxxx <br /> 1 <br /> V TANK FEE = 850.00/TANK (Prior to January 1,Id <br /> 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 19881991 1992 1993 1994 1995 1996F (multiply # by fee forA each year applicable) xxxx xxx% XXXXXXXX S <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xXxx xxxxXxXX S <br /> L <br /> I STATE SURCHARGE <br /> T <br /> Y # Tanks x $8.00 1988 through 1990 1991 through 1996 1997 <br /> (Enter aobunt and year) <br /> xxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxx S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) 3OIZ05—00 0177 4 A73 <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) J X $234.00 S 702 •m <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimm/FACILITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 mini" $ <br /> R REPAIR FEE (workplan Review 8 Construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimua/FACILITY) = $234.00 minimum S <br /> MTRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S 7Qz • �� <br /> FOR OFFICE USE ONLY <br /> ......_...._.._.............................................._......_..._._.......____...__. __.: _-.: ...._...... — ____ ...........__.._......__..............._........_..._............_......::::::::::::::::::::: <br /> iii__._. .::. v_i_" :'._ ::iii <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> _ __ _ _ ____ _ _ _ _ __ _______ <br /> EH 23 032 (REVISED 4-24-97) <br />