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SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH OIVSION <br /> UN ROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY COOTT NAME <br /> I <br /> T <br /> 'E FACILITY ADDRESS SITE PHONE # with AREA COPE <br /> 1 t ; cC 2Q' 43 3213 <br /> CITY STATETIP CODE ;9 of TANKS <br /> S._Q6 �j at SITE <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I ! 176 <br /> C MAILING ADDRESS APPLICANT PHONE � WITH AREA CODE <br /> A p �r v1 �,.r„ C} 3 r� 1 Z L <br /> T CITY STATE ZIP CODE I TYPE of APPLICATION .TM ST 47;&,) <br /> o C r LlI (Ctosure, InstaLLation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FE. (Prior to January 1, 1441) = 5100.00 1986 1987 1988 1989 1990 <br /> A X <br /> C XXX XXXX XXXX XXXX XXXX S XXXXXXXX <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX I XXXX I XXXX XXXX XXXX 5 XXXXXXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> M Tanks = 1988 11989 1990 1991 11992 1993 1994 1995 1996 1997 1998 <br /> F (mut r1pLy # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX (XXXX f I I I I I 5 <br /> C I <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX (XXXX I ! 5 <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 S <br /> T <br /> Y r Tanks x 58.00 1988 through 1993 (S56) 1993 through 1997 (S5T) 1_9 98 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX X)O(XXXXXXXXXXXXXXXXXXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-P(ace) f TANK I.O. T(s) <br /> L <br /> 0 <br /> S C''_OSURE FEE = 378.00/hour (3 hours minimum/TANK) ( 9 TANK(s) X 5234,00 = 3 <br /> Ul TEMPORARY CLOSURE (Plan Review 3 Inspections) TANK 1.0. 4(s) <br /> R <br /> Ei TEMPORARY CLOSURE FEE = 378.00/hour (3 hours minimum/FACILITY) i x234.00 minimum 3 <br /> PI INSTALLATION PLAN CHECK (Ptah Review & Construction Inspections)t TANK I.O. T(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 378.00/hour (8 hours minimurt/FACILITY) = 36Z4.00 minimum 5 <br /> RREPAIR FE (W <br /> orkplanlan Review $ Construction inspections) ' TANK I.O. r(s) <br /> EI <br /> TANK LINING 'REPAIR FEE = 378.00/hour (3 hours minimum/TANK) * TANK(s) X 5234.00 = 3 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 378.00/hour (3 hours min./FACILITY) = SZ34.00 minimuny 1• - P'41 S <br /> R <br /> PIPING REPAIR FEE = 578-00/hour (3 hours minimum/FACILITY) = 5234.00 minimum 3 <br /> Ml `RANSFER FEE = 320.00 I UNAUTHORIZED RELEASE E'/ALUATICN = 378.00/hr 3 <br /> i <br /> S I <br /> Ci C:HSULTATION FEE = $78.00/hrI SAMPLING INSPECTION FEE = 378.00/hr I i 3 <br /> TOTAL DUE � S <br /> FOR OF=ICE USE ONLY <br /> M.... <br /> STEEPS i CCMPUTER x lI LCC CODE I DIST CODE AMCUNT .RECEIVED CHECK -/CASH -RECEIVED 3Y — I ---DATE RECrIVED- <br /> :.. <br /> EH 23 032 (REVISED 1-12-98) <br />