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SAN JOAQUIN COOArf PUBLIC HEALTH SERVICES - ENVIRONMENTAL HLI a DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I G/rI/E B yo y <br /> T <br /> 'E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L z7 &-ee� Ofi�a�� Y 3 3-oSoz <br /> A CITY LOO/ 5_TA ZIP CODE # of TANKS <br /> at SITE <br /> P <br /> P APPLICANT/BILLING NAME kAPPLICANT CONTACT E <br /> L p(./ G F N ESL/'O <br /> I <br /> C MAILING ADDRESS ICANT PHONE # WITH AREA CODE <br /> " 33 o Kvi Coves Wo6 <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION G�sv&E <br /> . "roc,Ci a.✓ gsyp (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 11988 F <br /> 89 1990ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00A %XXX X%XX %XXXXX XXXX S %XXXX%XX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %%%X X%X% %XX% %%XX %%%X S %%XXXXX% <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1988 1989 1990 1991 11992 1993 1994 1995 1996 1997 1998 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX %XXX XXXX XXX% S <br /> C <br /> 1 TANK PENALTY FEES ASSESSED XXXX %%%% X%%X XXXX XXXX I $ <br /> _ L 5 <br /> 1 STATE SURCHARGE FOR NEW FACILITIES ONLY-S18.50 <br /> T <br /> Y # Tanks_ x 58.00 1988 through 1993 (S56) 1993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 xXXXXXXxxxxxxxxxxxxxxxxXXXX xxxxxxxXXXxxxxxxxxxXXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) lltl <br /> L <br /> 0 CLOSURE FEE = E78.00/hour (3 hours miniaun/TANK) I # TANK(s) X 5234.00 5 Z QO <br /> S <br /> U TEMPORARY CLOSURE (Plan Review S Inspections) TANK I.D. #(s) <br /> R iS <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimw <br /> P INSTALLATION PLAN CHECK (Plan Review S Construction Inspections) TANK I.D. #(S) <br /> — <br /> L <br /> A 5 <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimun/FACILITY) = S624.00 minimum <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.O. #(s) <br /> ES <br /> u <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours miniam/TANK) # TANK(s) X 5234.00 <br /> A S <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) $234.00 minimum <br /> R S <br /> PIPING REPAIR FEE = 578.00/hour (3 hours mi nimm/FACILITY) = 5234.00 minimum <br /> Ell M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> SI S <br /> ClCONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br /> TOTAL DUE s- 7 <br /> FOR OFFICE USE ONLY <br /> a.::.�. ...._...:. ............:..m:._....... _.. ::� <br /> p::��:.:.:.xu_:._:!4ui:F�.litrs:C!u. <br /> — _ SUEEPS # COMPUTER # LOC CODE DIST CODE AMOl1NT RECEIVED I CHECK d/CASH RECEIVED BY GATE RECEIVED <br /> MOM ..r <br /> Fu Ji OX7 (RFVISFO 1-12-98) <br />