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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH OIVSI0M <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SFACILITY SITE NAME- FACILITY CONTACT NAME ' <br /> I l l Ons <br /> E FACILITY ADDRESS �+ SITE PHONE Y with AREA CODE <br /> L '5- <br /> CITY <br /> CITY TATE ZIP coos / of TANKS <br /> A S 4- - J r! at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE 0 WITH AREA CODE <br /> A <br /> M _ <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> 1 SU �ai <br /> 1986 1987 1988 1989 1990 i <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A <br /> C XXXX xiDa oo dao = <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX 'X)W( ( 0� O 1001 <br /> w S <br /> LD <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> S Tanks = 1 1986 1987 1988 1 1989 1 1990 11991 11992 1993 1994 1995 1996 <br /> F (multiply s oy fee for I <br /> _ <br /> A each year appUcahle) n= XXXX J D b 17�I I I S /� <br /> I TANK PENALTY FEES ASSESSED XX)C( I XXXX 160160 150 I?D 1110 S <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK ('Due every 5 years) See California H 3 5 Code, Section 25287 <br /> T <br /> Y 0 Tanks I z 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S I <br /> C PERMANENT CLOSURE (Re "L or Authorized Closure-in-Placa) TANK I.D. 0(s) <br /> L <br /> DI CLOSURE FEE = 578.00/hour (3 hours minimm/TANK) 0 TANK(s)_ X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review i Inspections) TANK I.D. 0(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 'lairs minim=/FACIL(TY) 5234.00 minimm S <br /> P INSTALLATION PIAN CHECK (Plan Reviw 5 Construction Inspections) TANK I.O. 0(s) <br /> Ll <br /> A <br /> 9 PLAN CHECK FEE = 578.00/hour (8 hours siniatm/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Carat,= ion Iromeetiors) I TANK I.D. 0(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.001hour (3 hours minima/TANK) I a TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hairs ain./FACILITY) = $234.00 ainimsa 5 <br /> R <br /> PIPING REPAIR FEE = S78.00/hair (3 haws minimNFACILITY) = 5234.09 minim5 <br /> N TRANSFER FEE = 520.00 UNAIRHORIZED RELEASE EVALUATION = 578.00/hr I S <br /> I <br /> S Q <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 978.00/hr <br /> SO / <br /> TOTAL GLEE S tl O <br /> FCR OFFICE USE awl? /9 p p n o-µe a. - 5- 9,3 Ivo Lq$-3-�' CQu11 LT13 <br /> SWEEPS x COMPUTER s I LOC CCOE I GIST CODE I AMOUNT RECEIVED I CHECK !/CASH RECEIVED ay I DATE RELIVED <br /> 9H " n'97 fREVISED <br /> 10-28-93 �"'� Page 11 <br />