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• • <br /> SAN JOACUIN COUNTY PUBLIC HEALTN SERVICES - ENVIRONMENTAL NFJILTX DIKION i 9 <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET j <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> (log,•) 1 ✓er` h ? Fuv,s �n>z eh <br /> FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 1-/5do S, /Aw `1 X09 - 3 3-)3 <br /> $ STATE ZIP CODE # of TANKS <br /> CITY //�� � L q at SITE <br /> A .S r(/Gk- 'Lam'! (�¢ /S� I , <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME .- [� <br /> L <br /> S' S'/t M vi C V 2�c S i-v�n- <br /> 1 ADDRESS <br /> C MAILING APPLICANT PHONE # WITH AREA CODE <br /> A is 3s �_ toc,SC LL� <br /> N STATE ZIP CODE T�APPLICATION <br /> CLI C4 <br /> T CITY ( Losu Insca LLation, etc.) <br /> �VLa 5 3 7 Lo <br /> TOTAL <br /> 1986 1987 1988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 I S <br /> A <br /> G xxxx xxxx I I 5 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> L 5170/TANK (After January 1, 1991) <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 11993 1994 11995 1996 <br /> F (multiply # by fee for I l 5 <br /> A each year applicable) <br /> C I S <br /> I TANK PENALTY FEES ASSESSED I x%Xx xxxx <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T 1991 through 1996 <br /> Y # Tanks z $56.00 1986 through 1990 <br /> (Enter amount and year) 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L # TANK(s) X 5234.00 = 5 <br /> 0 CLOSURE FEE = S78.00 <br /> (3 hours minimtWTANK) <br /> AL 1 <br /> S TANK I.D. #(s) <br /> U TEMPORARY CLO (Plan Review & Inspections) <br /> R <br /> E TEMPORARY CLOSURE E = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ 234.00 ' S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #Cs) <br /> L <br /> AS <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minim /FACILITY) = 5624.00 minimum <br /> RI REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) % $234.00 = IslA I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimmR <br /> PIPING REPAIR FEE 578.00/hour (3 hours minium/FACILITY) = 5234.00 mini mum <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I , S <br /> I <br /> S 5 <br /> C CONSULTATIO=FEE . 8.00/hr I SAMPLING INSPECTION FEE = 578.00/hr <br /> TOTAL DUE 5 <br /> FOR OFFICE-USE LT <br /> SWEEPS # COMPUTER # LOC CODE I DIST CODE I AMOUNT RECEIVED CHECK ;I/CASH RECEIVED BY I DATE RECEIVED <br /> EH 23 032 (REVISED 11-1-92) Page 11 • <br />