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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> 1 b 1 nn Sr �.1 ctR Srr <br /> T <br /> E FACILITY ADDRESS SITE PHONE N with AREA CODE .. <br /> t <br /> CI . STATE Z(PCODEN of TANKS <br /> A /iJiJa �3 at SITE <br /> P <br /> PAP LIC <br /> I ANT/BILLING NAME APPLICANT CONTACT NAME <br /> 1 ? <br /> C MAIL 0 ADDRESS APPLICANT PHONE 0 WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE 11TYPE CODE TYPE of APPLICATION ' <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior t6 January 1, 1991) 5100.00 <br /> A xxxx xxxx xxxx xxxx xxxx % xxxxxxxx <br /> C <br /> I FACILITY PENALTY FEES ASSESSED (If Applleable) xxxx xxxx xxxx xxxx xxxx" - % xxxxxxxx ;,;. <br /> I <br /> V TANK FEE + 550.00/1ANK (prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> N Tanks = �Q� 1987 1988 1989 1990 1 1991 1 1992 1 Ir3j 1994 1 1995 1996 1 1997 <br /> F (multiply M by fee for <br /> A each year Applitable) xxxx xxxx xxxx xxxx xxxx $ <br /> �. 1 TANK PENALTY FEES ASSESSED xxxx xxxx xxxx xxxx xxxx 74 17M, <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY • 1iB.50 Is <br /> T <br /> Y N Tanks x $8.00 1988 through 1990 (f56) 1901 through 1996 (%56) 1997 618 <br /> i <br /> SURCHARGE FOR 1997 xxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx f <br /> i <br /> C PERMANENT CLOSURE (Removal or Authorlted Closure-in-Piece) TANK I.D. M(a) <br /> L <br /> 0 CLOSURE FEE + $78.00/hour (3 h6Ure minimum/TANK) M TANK(s)_ K $234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review Z Inspections) TANK I.O. k(s) <br /> R <br /> E TEMPORARY CLOSURE FEE + 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum f <br /> L INSTALLATION DLAN CHECK (Ptah Review A Construction Inspectlona) TANK I.D. No) ` <br /> I. A - <br /> N PLAN CHECK FEE • $78.00/hour (8 hours minimum/FACILITY) 5624.00 minimum t <br /> R REPAIR FEE (Workpian Review d Construction Inspections) TANK I.D. p(s) <br /> E <br /> P TANK LINING REPAIR FEE • 578.00/hour (3 hours minlmum/TANK) q TANK(s) x $234.00 t <br /> 1 <br /> A <br /> I TANK RETROFIT REPAIR FEE • 978.00/hour (3 hours min./FACILITY) + 5234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE • $78.00/hour (3 hours minlmm/FACILITY) 5234.00 minimum 9 <br /> N TRANSFER FEE + 120.00 UNAUTHORIZED RELEASE EVALUATION + 1178.00/hr S <br /> 5 <br /> C CONSULTATION FEE + $78.00/hr SAMPLING INSPECTION FEE 978.00/hr 5' <br /> TOTAL DUE 5 <br /> (N <br /> FOR OFFICE USE ONLY , m rinlNmun!!!n!mennlnnemn!elnm!!mnlnlmm�!!n mon!mollm!nnl!!Imnnennlnanmm�vmnnnnrnmmnnpmm!✓e! n. , <br /> !1m nrnlnimm�rii nxiF!r!!l iHNmn nnlmnnn!Im11 n 111 mmmnnin lminlln�iin�igl mm��1n�m!u!, 1, !!n nm ,i;,lilr l9! .: .!,r ,r,l :.: ,n r ,,;Ir lu I .:�..111111:I!.n,l liar.umm,:.lunllilnn!Itim:!nNlllln:!!:.L:,m"Illi)IInQ <br /> IINI�p11111 111.Ii 11...L 1111 !1 <br /> SWEEPS N COMPUTER N LOC CWE DI AMOUNT DECEIVED— CHECK N/CASH RECEIVED BT DATE RECEIVED Im <br /> p Llil!ml�l it!I !Vmll 11 L !1! r l f 1 -: II? :,it 7T Nil <br /> rmi!Im _aln I J1.!. ! .Il ummx!I�tl <br /> .r r 1 :: :: .r:: ,... i 1! ..vi nl 11 I,II!n 11.111!.!1�a <br /> IIIIL4 nl rlir N.!Pb11INMi 1 r ! .:i.... "' <br /> —.. —. -.- .--..r�-n a •t a'f♦ _;v..:::p::/...e. <br />