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SAN JOADUIN CQUNTY.BLIC HEALTH SERVICES - ENVIRONMENTAL HEALTf. VSION UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET S I FACILITY SITE NAMEFAAC-ILITY L_ r /7.1114r� CONTACT NAME Ro4pe 1987 ( !� o ly-- ., i W1 or M-P 554e -r T $ A I E FACILITY ADDRESS SITE PHONE # with AREA CODE s 6,l A 0 A I e Z a0 j) 7?;2--J6 XXXX XXXX XXXX XXXX XXXX CITY I k 7© STATE CA ZIP CODE # of TANKS tt at SITE !v P J () G iL C P L APPLICANT/BILLING NAME te. APPLICANT CONTACT NAME F r 17" 1 C fl-nTv- a.crrQC-, c c- k, o e I T FACILITY PENALTY FEES ASSESSED (If ApplicabLe) C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE A5` 5 ln/i W' 0. $ XXXXXXXX T CITY r 1 p c ! ! C3 'y` STATE ZIP CODE `7457, S TYPE of APPLICATION (Closure, Instal anon, etc.) TOTAL C PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) TANK I.D. #(s) L 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ S U TEMPORARY CLOSURE (PLan Review & Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) 1986 1987 1988 1989 1990 $ A I ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 $ R N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ 6,^4. 0 0 XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX A CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ C T FACILITY PENALTY FEES ASSESSED (If ApplicabLe) XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX I V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) E # Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998y1}p�>r�pj F (muLtiply # by fee for XXXX XXXX XXXX XXXX XXXX $ 1 rl�i 0 0 A each year applicable) I / C I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ L I STATE SURCHARGE T Y # Tanks—j— $8.00 1988 through 1990 ($56) 1991 through 1996 ($56) 1998 p XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX $ SURCHARGE FOR 1997 C PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) TANK I.D. #(s) L 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ S U TEMPORARY CLOSURE (PLan Review & Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) TANK I.D. #(s) E P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) L $ A I A $ R N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ 6,^4. 0 0 TOTAL DUE $ S FOR OFFICE USE ONLY .asta SWEEPS # R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) E P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ A I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ R PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ I S C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ TOTAL DUE $ S FOR OFFICE USE ONLY .asta SWEEPS # .::.:::::: COMPUTER # I ::::::::::::::::::: LOC CODE I ..:.. :.......::::::::::::::::::::: DIST CODE ::::::::::;::::::::;:.,.......:::::::::::::::::::::::::::::::::::::::::: ,.,...... AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED EH 23 032 (REVISED 1-12-98)