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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> IFACILITY SITE NAME / FACILITY CONTACT NAME <br /> TAjjj 14`_� /�.GL tom'C9'r'�.'✓t GC �£U/cL-"1. <br /> E FACILITY ADDR/F,�$'�S� / SIT u-PHO NE 9 with AREA CE— <br /> CITY STATE ZIP CODE # TANKS <br /> Aat SITE <br /> P �J <br /> P APPL T/BILLING NAME / APPLICANT CONTACT NAME <br /> L G�u v��(S✓i� C C� yl�1�P C' <br /> C MAILING ADDRESS - n APPLICANT PHONE # WITH AREA CODE <br /> A d C <br /> M a/Q4� <br /> T CITY STATE CODE T PnstaLtON e c <br /> - LClosure, Installation, ate.) /�. <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> A ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 %XXX %X%X I&O- / L <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %XXX %XXXI&O Iuci CGt <br /> 1 <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks 1 1986 1987 11 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply Al by fee for <br /> A each year applicable) XXXX XXXX 5 G c S r 1� 1 (� ( o f �� <br /> I TANK PENALTY FEES ASSESSED XXXX XXX% <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H d S Code, Section 25287 <br /> T <br /> Y # Tanks x (56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE - 578.001hour (3 hours minimum/TANK) % TANK(s) X 5234.00 = f <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review d Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br /> R REPAIR FEE (Workplan Review d Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE - 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 mini mm f <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr f <br /> I <br /> S <br /> C CONSULTATION FEE 578.00/hr SAMPLING INSPECTION FEE = $78.00/hr f' <br /> TOTAL DILE <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> � 5 3 <br /> EN 23 032 (REVISED 10-28-93) Page 11 �, <br />