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SAN JOAOUIN COUNTY -ELIC HEALTH SERVICES - ENVIRONMENTAL HEALTH ^1VSION <br /> UMDER,,AD STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> 1 &,') 6l7 c 1 it- o o <br /> 'E FACILITY ADDRESS S1TE PHONE 7 with A EA CIODE <br /> & Zo qt.(.— :3�(i <br /> CITYSTATE ZIP CODE X of TANKS <br /> A JC2 15 at SITE <br /> JIP _ ,i3O <br /> P APPLICANT/BILLI G NAME APPLICANT CONTACT NAME n <br /> L C O �J rJ Cu ERI /L <br /> C MAILING ADORES APPLICANT PHONE N WITH AREA CODE <br /> K (1,; Is,,0 W QC,- /100b <br /> T CITY STATE ZIP CODE PLICATION <br /> �C TO(�l 52p5 TY osure stallation, etc.) <br /> TOTAL <br /> 1986 11987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A %XXX %XXX � X%XX X%XX %X%X S XXXXXXXX <br /> C <br /> IFACILITY PENALTY FEES ASSESSED (If App(icable) I XXXX I Xxxx xxxx I %XXX Xxxx S XXXX%XxX <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 7991) <br /> E <br /> At Tanks = 1988 1989 1990 1991 11992 1993 119% 1995 11996 11997 1998 <br /> F (multiply ;y—fee for <br /> A each year applicable) X <br /> XXX XXXX <br /> XXXX I XXXX %XXX i I $ <br /> C <br /> 1 TANK PENALTY FEES ASSESSEDI XXXX %%XX I XXXX I XXXX (XXXX I I I I I i s <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=Si8.50 S <br /> T <br /> T # Tanks x 58.00 7988 through 1993 (S56) 7993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 X%%XXXX%%%XXXXXXXXXXXXXXXXX %XX%XXXXXXXXxxxxxXXXX%% l S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in•P(ace) TANK I.D. x(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minirmm/TANK) I 9 TANK(s)� X 5234.00 a S L7 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. x(a) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 mini mJ!A S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. X(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = S78.00/hour (8 hours minim=/FACILITY) = S624.00 minimuim S <br /> R REPAIR FEE (Workptan Review & Construction Inspections) I TANK I.D. N(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) I « TANK($) _ X 6234.00 = , $ <br /> A <br /> I TANK RETROFIT REPAIR PEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minim= S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimums <br /> M TRANSFER FEE _ $20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I S <br /> 1 I I 1 <br /> s 3 <br /> C CONSULTATION FEE = 678.00/hr I SAMPLING iNSPECT70N FEE = 578.00/hr I $ <br /> TOTAL DUE $ Y � <br /> FOR OFFICE USE ONLY _ <br /> SWEEPS Y COMPUTER 7 LOC CODE DIST CODE AMOUNT RECEIVED I CHECK d/CASH RECEIVED BY DATE RECEIVED - <br /> �ti <br /> p. S <br /> v:➢�.+_B'.:9m.'°!!k!^!�14.^._.._..?:!:-!!lRTimnv_nn;,:;-�on�.�_.t: L�:..'�T_r P^_--s=:T_^Gi:iE!L�i?Gi� ____ <br /> cu Pt n'(7 tRFVISFO 1.12-98) <br />