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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNOr' -ROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTA�, NAME <br /> T S land -eleven 51ort 1733`}' <br /> E R Ss SITE PHONE # with AREA CODE <br /> FACILITY AD <br /> �}5g7� N. Pc�ghi Ave <br /> CITY STATE ZIP CODE # of TANKS <br /> A o�ktvn GA °15207 at SITE CnewD <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L R H L ( <br /> D�Si n (�rou , 1 n� tai a pian i no <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A &56 Hou, Ave-nue, . W5c)4 (alto) Co467-4003 <br /> N <br /> T CITY STATE 2IP CODE TYPE of APPLICATION <br /> Sa6ramento Ga `1582 Closure, [nstat(ation, etc.) 1nS�llati0+1, <br /> TOTAL <br /> 1986 11987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX %%%% X%%X XXXX X%%% S K%%%%%%% <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX I XX%X XXX% %XXX XXX% S XX%%%%X% <br /> 1 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) el'5170/TANK (After January 1, 1991) <br /> E — <br /> # Tanks = 2 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 <br /> F (muLtiply # -by fee for <br /> A each year applicab(e) XXXX XXX% XXXX XXX% XX%XS 4 <br /> 0 <br /> •L27 <br /> C <br /> I TANK PENALTY FEES ASSESSED XX%X XXXX XXXX %X%% XXXX S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 J5 <br /> T <br /> Y # Tanks 2— x 58.00 1988 through 1990 (S56) 1991 through 1996 (S56) 1997 <br /> SURCHARGE FOR 1997 %XXXX%XXX%%XXXX%%X%XX%%XXXX %XXXXXXXXXXXXXXXXXXXXXX S 1Ly•00 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.O. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 3 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 8234.00 minimum S <br /> 0NP I.D.INSTALLATION PLAN CHECK (Plan Review 3 Construction Inspections) TANK #(s) <br /> L <br /> PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624-00 minimum S �Z'q <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78-00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = 878-00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = 820.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> Cl CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE 5 1Cl�• CO <br /> FOR OFFICE USE ONLY <br /> :::as:: : ........ <br /> ......_::!__::__:_:__ v.=:: <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE I AMOUNT RECEIVED CHECK #/CASH I RECEIVED BY I DATE RECEIVED a <br /> EH 23 032 (REVISED 5-27-97) <br />