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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 /> T ESf <br /> E FACILITY ADDRESS SITE PHONE X with AREA COOS <br /> r / E. 14 <br /> CITY ;TATE ZIP CODE it of TANKS <br /> A C at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L F <br /> CMAILING ADDRESS 00RI,9L b 'D, - 6 CO e— APPL( T P ' <br /> d WITH AR CODE <br /> M <br /> T CITY 7 T ZIP CODE TYPE of APPLICATION <br /> ''_S (CLesure, Installation, etc.) <br /> �aj& <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 2100.00 <br /> A XXXX c= goo /,-)C) faoc� <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX XX)0( SOV I1�0 S <br /> L <br /> V TANK FEE 250.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> At Tanks = —j— 1986 1987 1 1988 1 1989 1990 1991 11992 1993 1 1994 1 1995 1 1996 <br /> F (multiply s by fee for <br /> A each year appLicable) =Cx =(x 50117 0 IQT It 7 /(1Gh I f 9'o <br /> I TANK PENALTY FEES ASSESSED XXXX I fcc 5 01170 I d 1761 1 f 8-0 <br /> L <br /> I STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California 4 S S Code, Section 25297 <br /> T <br /> T X Tanks z $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK 1.0. s(s) <br /> L I <br /> 0 -tD <br /> I CLOSURE FEE - 1178.00/hour (3 hours minimum/TANK) k TANK(s)_ X $234.00 = a f <br /> S <br /> U TEMPORARY CLOSURE (Plan Review b Inspections) I TANK I.D. #(a) <br /> R <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimum/FACILI7Y) $234.00 minimum f <br /> PINSTALLATION PLAN CHECK (Plan Review f Construction Inspections) TANK I.O. i(s) <br /> L <br /> A <br /> N PUN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ <br /> R REPAIR FEE (WorkpLan Review 8 Construction Inspections) I TANK I.D. ICs) <br /> E <br /> P TANK LINING REPAIR FEE = 11$.00/hour (3 hours minimaWTANK) I B TANK(s) _ X $234.00 3 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 278.00/hour (3 hours min./FACILITY) _ $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minim n/FACILI7Y) = 5234.00 minimum $ <br /> 91 TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION - $78.00/hr S <br /> I � <br /> Cl CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE - f78.00/hr I S <br /> TOTAL OUE 2 <br /> FOR OFFICE USE ONLY <br /> SWEEPS s COMPUTER d LOC CODE DIST CODE AMOUNT RECEIVED CHECK ;*/CASH RECEIVED BY I DATE RECEIVED <br /> EH 23 032 (REVISED 10-28-93) +a.� Page 11 <br />