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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDE-"ROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME — FACILITY CONTA,- .,AME <br /> T bland -eleven 5fier� 173 d. <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & 4501 1\:, Pershivtaj Ave <br /> CITY 1 STATE ZIP CODE -7 # of TANKS <br /> A S I oo14}OY l G,4 - 1�7 ! at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> RHL_ Dee n C-)rnu Inc. fai a C>(anino <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A leo 1-bw� ven )o `JC14 (giCo) <o4Co-4�3 <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION Tank <br /> `J�Lfanlen{O GA (Closure, Installation, etc.) C.105ure. <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 8100.00 <br /> A XXXX XXXX XXXX XXX% XXX% S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXX% XXXX S X%%XXXX% <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) S17n/TAN)F (After January 1, 1991) <br /> E <br /> 0 Tanks = 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 11997 <br /> F (multiply # -by fee for <br /> A each year applicable) %XXX XXXX %%XX XXXX X%XX I S <br /> C <br /> 1 TANK PENALTY FEES ASSESSED XXXX XXXXXXX% XXXX XXXX S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = 518.50 IS <br /> T <br /> Y # Tanks x 58.00 1988 through 1990 (856) 1991 through 1996 (856) 1997 <br /> SURCHARGE FOR 1997 XXXX%XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXX%XXXXXXXXXXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s)� X $234.00 = S 70 Z00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.001hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> R 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) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I S <br /> I <br /> Cl CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = $78.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> ..............._...._._..._....__.........__.._._:__m...... :::ail[[tt_ _ ._:i-'s_ <br /> SWEcPS # I COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH I RECEIVED BY I GATE RECEIVED <br /> S <br /> EH 23 032 (REVISED 5-27-97) <br />