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SAN JWOUIH 0 PUBLIC HEALTH SERVICES - ENVIRONMENTAL Id DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME / FACILITY CONTACT NAME <br /> I <br /> T n <br /> E FACILITY ADDRESS C ! SITE PHONE # with AREA CODE <br /> a c(L T <br /> A CITY .71. ^_ CE ZIP CODE # of TANKS <br /> at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L 5UA 1yv AE/q .f/n>4N <br /> 1 <br /> C MAILING AD RESS APPLICANT PHONE If WITH AREA CODE <br /> A S- <br /> N <br /> T CITY (..� U�y--�� STATEI ZIP CODE TYPE of APPLICATION <br /> JGIL G,5`Lc� (Closure, Installation, etc.) <br /> I - cryo a y TOTAL <br /> 1986 1987 1988 1 1989 1 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A XXXx XXX% xxxx XXXx xxxx $ xxxxxxxxxxxxX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) XXXx xxxx xXX% XXXX xxxx % xXxxxxxxxxxxx <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) 1170/TANK (After January 1, 1991) <br /> E <br /> # Tanks 3 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 199y <br /> F (muttiply # by fee for <br /> A each year applicable) xxxx xxxx XXX% xxxx xxxx 70 <br /> C <br /> TANK PENALTY FEES ASSESSED X%%% %%%X xxxx xxxx XXXx f• <br /> L <br /> I STATE SURCHARGE eac TANK (Due every 5 years) See California H 8 S Code, Section 25207 <br /> T <br /> Y # Tanks= x SIM —5?- 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> $ !1_ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) 7 <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 f <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 6 Inspections) TANK I.D. N(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimus S <br /> P INSTALLATION PLAN CHECK (Plan Review a Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours mini mum/FACILITY) _ $624.00 minimum f <br /> R REPAIR FEE (Workplan Review a Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) _ X 1234.00 = f <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minima/FACILITY) _ $234.00 mini arm S <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION - 178. f <br /> 1 <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = S78 hrigg <br /> 2 S <br /> TOTAL DUE <br /> SAN JOAQUIN COUNTY J <br /> FOR OFFICE USE ONLY PUBLIC HEALTH SERVICES <br /> enmm!x!!nee:a!me!nannr!na!mass::a!ne:!-1.!!s!!m!nen!man!mr.!!!!ax:xn:e!na!!n!!!n!men�!nma!!masa:nn!z!!m!ens!amnnm!!!nneam!e!n. !! ! :=m:!:,nrnnnnvn!!an!n!mm!xamnm!m!m!msmmn! <br /> nnmmn!a't iu a,r ..:!...... !nrxaa...... ..nn. ..muu.... ..nrinaar.:ni .m!r.:aan:a:n sin r:nnnnx:n;nnn nn:ran amm:u!! ::rr:�i::!i� ! i!r ii� :nx�ri!ii6i!riaxxanrr:m!rax aai:amxn::mmmxxxm!�� <br /> 1 11 41 <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMWNi RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> f 5 <br /> !e!mmn.!ssrn.!anm!nnmx r!!!!!!e!na!me:;;,::m::!::::::::::::• ::::: eev!ma!!m!!!.!!!n!!.^.n.m n!anmm�!rn me n ::! ::! / <br /> nanxu:minxe!!a.:u:n!!am:nasnnsar::aua!ernnnu:annnnrnnxnunnnnnnnnnm�!xnrxnex!!a!mann!nxuxxnnn;n;!annmmunamm�annnunnxunnn!unnnmannnm iannxaunnnununmiiii!iiriininmini!nadnnnnnnnnnnnnnnnnnnnmm�nnmx�!x <br />