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SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME / FACILITY CONTACT NAME <br /> I G C/ fL �4M6/n F 4 <br /> T <br /> E FACILITY ADDRESS / SITE PHONE # with AREA CODE <br /> 8 U L/ 5-, <br /> CITY // [ STATE ZIP CODE # of TANKS <br /> P ��v crE o4 `75 30 at SITE <br /> PAPPLICANT/BILLING NAME / APPLICANT CONTACT NAME <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N- <br /> T 19. o , 13 ox /y� y Ca�9J vc�& <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> S �U c/C�v>1 '(� qs ��/ (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1 1988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A /OD' /00d.100cry UV Soo,00 <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX /oJ (;(j loo S ,3 o O .00 <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks - _L 1986 1 1987 1 1988 1 1989 1990 1991 1992 1993 1994 1995 1996 <br /> EF (mLtipLy # by fee for year applicable) � $0� 5�D' D ' 70 /7 S5�o-QL7_PENALTY FEES ASSESSED XXXX XXXX SomSQ SO / 70 /7U o .OE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8nks x 556.00 1986 through 1990 1991 through 1996 <br /> er amount and year) <br /> 56 S(a Y 5//d - coo <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 = 5 <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 minimum/TANK) # TANK(s)_ X $234.00 = 5 <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimus 5 <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> 1 <br /> S <br /> C CONSULTATION FEE - 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE a, <br /> FOR OFFICE_ USE ONLY <br /> 3 SWEEPS # COMPUTER # LOC CODE DIST CODE I AMOUNT RECEIVED I CH K /CASH RECEIVED 8Y DATE RECEIVED <br /> .__.a_._......._-----0-0..:�. _._...__...`./`7 e�.N$ ......... /n <br /> -- <br /> EH 23 032 (REVISED 11-1-92) Page 11 �..i <br />