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SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> '92GROUND STORAGE TANK PROGRAM - FEE WORKSHE''- <br /> S FACILITY SITE NAME ` FACILITY COM'fACT NAME <br /> T 1"11 1'tG � SGTr,eSSC <br /> E FACILITY ADORE SS SITE PHONE # with AREA CODE <br /> s S�xj4-h Ar + LQINQ01 q S -a 441 <br /> CITY (,S�TApTE ('ZIP CODE I # of TANKS <br /> A �T�..I�-1 Cyd V1 -I�d ��p at SITE d <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I Seward L . 5chrede! 00-15-FrvcI-;01 e(A.✓r-( 5cAp-edu- <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N <br /> P. C. P -7785 1(31 <br /> T CITY/� �� STATE ZIP CODE TYPE of APPLICATION <br /> CA �r�,./a—� (Closure, Instaltation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX %XXX XXXX XXXX XXXX S %XX%XXXXXXXX% <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX X%XX %XXX XXXX %XXX E %%XXXXXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 11992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> Aeach year applicable) XXXX XXXX XXXX X%XX XXXX E <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX %XXX XXXX E <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.O. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimm/TANK) # TANK(s)�_ X 5234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FAL]L1TY) 5234.00 minimum E <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.O. #(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = 5624.00 minimum E <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK 1.0. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) # TANK(s) X $234.00 = E <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R E <br /> PIPING REPAIR FEE = 578.00/hour (3 hours mini minimum/FACILITY) = 5234.00 minim <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 9 <br /> I <br /> S = 578.00/hr S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE E <br /> FOR OFFICE USE ONLY <br /> ME- <br /> SWEEPS # COMPUTER # LOC CODE I DIST CODE A RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> E <br />