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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> UNDF- -'20UMD STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME Sf��Kd-ice FACILITY CONTACT NAME <br /> T {�, GRHr►US ; U <br /> E FACILITYADDRESS SITE PHONE # wit AREA CODE <br /> a& SI S . 1q;r jQor f Wtl ao9 9q-G - 077--- <br /> i CITY STATE ZIP CODE # of TANKS j re W-*-µ2a(. <br /> A J—onJ C4' 5 at SITE <br /> P / <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L I t Gl��i ws o.� S �-Arr G aer <br /> I <br /> C NAILING ADDRESS APPLICANT PN # WITH AREA E <br /> A S. i r 9 G - 77 <br /> T CITY tvv K/L.Q S -4;3L <br /> STATE ZIP CODE TYPE of APPLICATION <br /> Seo (Closure, Installation, etc.) <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A XXXX XXXX XXXX XXXX xxxx E XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If AppLicab(e) xxxx XXXX xXXX XXXX XXXX S xxxxXxxxxxXxx <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1 1987 1 1988 1989 1990 1991 1 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year appLicable) XXXX xXXX XXXX xXXX XXXX 170 M 170 j7jq /7Q <br /> I TANK PENALTY FEES ASSESSED XXXX I xXXX xxxx I XXXX XXXX 7 0 117b 1/70 17,01/101 $956) <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y # Tanks—i-- $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) 5 CO/ o� 6-G <br /> $ <br /> C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = E <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 minimum/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = (624.00 minimum S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) _ X 5234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = S234.00 minimum E <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 mini mm E <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr E <br /> I <br /> S <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = S78.00/hr E <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> ......._..._........_...................................._ _:._.........:"::'e':_.c___=.: ' :i-doe-eeeeee'Fri:::::::::::::::::_:iee5v:_._.:._c...... ............ <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> E _ <br /> ....................................................................._.............__:_:::__:::-,i::s?s;,deo._ -_:_,__-::__:..._.._:':_.._::::.___-_-::::=-_r_d_y:.=..e:::::::::::::::: :eeee::,__-_--- <br /> ....- <br /> :. .:.M.M <br /> o&4 �� � :::..:........:.: <br /> .. .. <br /> T <br />