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AJ <br /> ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HA DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE MANE LE/ 12n1E2aFAILITY Sk ,yC/ONTACT AME <br /> I ^ <br /> T PHONE # with AREA CODE <br /> E FACILITY ADDRESS I �AJQ_ <br /> S !n' # of TANKS <br /> CITY �,�� Iat SITEA JI l.C���MLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAMEL1 LICANT PHONE # NITH AREA CODE <br /> C MAILING ADDRESS o 1.3ANTYPE of APPLICATIONl.1T CITY (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = E100.00 XX%% xxxx xxxx xxxx xxxx S xxxxxxxxxxxxx <br /> A <br /> C xxxx xxxx xxxx xxxx xxxx S xxxxxxxxxxxxx <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> 1 <br /> V TANK FEE _ $50.D0/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1 ) <br /> E 1996 <br /> 9 Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 <br /> F (multiply # by fee for S <br /> A each year applicable) X%xX xxxx %XXX xxxx xxxx <br /> C S <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx xxxx xxxx xxxx <br /> L <br /> 1 STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> T # Tanks_ 1988 through 1990 1991 through 1996 <br /> x 556.00 <br /> (Enter amount and year) y <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L # TANK(s)�_ X 5234.00 = S Li Ica. <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /> $ TANK I_D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review 6 Inspections) <br /> R f <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum <br /> EA ALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> - 5624.00 mini mum $ <br /> LIIECK FEE = 578.00/hour (8 hours minimum/FACILITY)TY) - <br /> R REPAIR FEE (Workplan Review 6 Construction Inspections) TANK I.D. #(S) <br /> E f <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours mininuNTANK) # TANK(s) __ X 5234.00 = <br /> A = 5234.00 minimum $ <br /> 1 TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br /> R $234.00 mini $ <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) _ E I <br /> N TRANSFER FEE = $20-00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> 5 $ <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $ <br /> 78.00/hr <br /> TOTAL DUE f L-+106 <br /> FOR OFFICE USE ONLY :.—::::::,.—::::__� .;,m!!r�:_T.:'c!r!_;!m! ! a==!Ee: :!=_ix; ear :!t:;^m!!!�-:-!!!n:me_!!::7:m:m!M <br /> y..h:_8u...._.._.:_._.v.__9......uu....__i!!m!!m�_3?_:q_:,.:e.._::.i.:n::=—:v,_e_i_^..__w,_�__.::..I. _.._.: <br /> p .. _... v :..:Eui�W:iiImSWWN'da:NYiiIJiL4uni1v2eLE!i;W9aiLS9:!!!?ii!14!�R;!tW:.:Jii:aii!li'J....T. <br /> �IIWSmYIu�'IL'Lu1uC:11Mo!—H11'u:u':Im',.id.:3.:::4P.xvlmiW:iL3cuswo_L+viv—'.. _ tiIL'lu"�—v-.._ 1m <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED r <br /> s:-imC-;P':!��L:2m;i!::!:i <br /> :t_................._...:.:.........:....._!t._. - _.. ::: mrdu:cmc:!u!mm" cu!!u!!avummu;arusr �'��!a <br /> :v��!:e :ium_!_,::�!�%:;ui�a. :u�'i�:m••���.��_+limo=3wi:�s�:::u!ruu <br />