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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACIL[ Y SIT N E FACILITY CONTACT NAME <br /> T <br /> -E FACILIT AODRES ' _ SITE PRONE with AREA CODE <br /> a <br /> .3.3 cv�ti Cao Mfr> - © �fa5 <br /> Aj CITY /STATE ZIP CODE at SITE <br /> KS <br /> G0� 9 <br /> P \✓7 <br /> P APPLICANJ/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A /Rt.,(/1�� <br /> NSTAT E ZIP CODE TYPE of APPLICATION G O-C: <br /> T CITY Q <br /> S- C fCfi •T q,s (Closure, Inst LLati n, etc.) <br /> TOTAL <br /> 1966 1987 11988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A %XxX xxxx I xxxx XXXX XX%% S XXXXX%%X <br /> C' <br /> TI FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX %%%X I X%X% %XX% S XXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E C <br /> I # Tanks 1988 1989 1990 1991 1992 11993 1 1994 1995 1 1996 1 1997 <br /> F (multiply # by fee for �,�y <br /> A each year applicable) xxxx XXxX XX xxxx XXIxxxx I) `7 !'10 !f <br /> ?oma 10 j ',Q �1D LS S0' ,Ao <br /> C <br /> Ij TANK PENALTY FEES ASSESSED I XXXX xxxx XXXX XXXX XXXX I Ci1a- 1RY I1D' 40� �D ('� Sr oao ' <br /> L' <br /> ISTATE SURCHARGE FOR NEW FACILITIES ONLY=StIr7T 109Q p r7p S 10 <br /> T qO 7 <br /> YI # Tanks x 38.00 I 1988 chrough 1993 (S56) 1993 through 1997 (S56) <br /> ! SURCHARGE FOR 1998 XXXXXXXXX%XXXXXXXXXXXXXXXXX xxxxxxxxxxxxxXxXXXxxxxx S g <br /> C PERMANENT CLOSURE (RemovaL or Authorized Closure-in-Place) TANK I.D. #(s) 1 <br /> L; <br /> 01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) j # TANK(s)_ X i234.00 = 3 .3 <br /> S' <br /> UI TEMPORARY CLOSURE (P(an Review a Inspections) TANK I.D. #(S) <br /> R <br /> EI TEMPORARY CLOSURE FEE = 576.00/hour (3 hours minimun/FACILITY) 5234.00 minimum S <br /> PI INSTALLATION PLAN CHECK (Plan Review a Construction Inspections)I TANK I.D. #(s) <br /> L, <br /> Al <br /> NI PLAN CHECK FEE = 578.00/hour (8 hours mininRWFACILITY) = 5624.00 minimum S <br /> RI REPAIR FEE (Workp(an Review a Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimus/TANK) # TANK(s) _ X 3234.00 = S <br /> A <br /> Ij TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimus S <br /> R <br /> li PIPING REPAIR FEE = 578.00/hour (3 hours minimus/FACILITY) = 5234.00 minimum S <br /> NJ TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> Cl CONSULTATION FEE = 578.00/hr j SAMPLING INSPECTION FEE = 578.00/hrAl.I I g V R od <br /> bLLc.K1 �ar .J�:y'�y1' . TOTAL DUE 3 <br /> FOR OFFICE USE ONLY G� ��'�"Y- d — <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK */CASH j RECEIVED SY j DATE RECEIVED <br /> - <br /> E4 23 032 (REVISED 1-12-98) nl IID.O r2,'�'3�9 <br />