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7-15-1998 11 :27A14 MOM • • p S <br /> SAN JOAaNIN COIAITY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH OIVSIOW <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE LlnR1C$MEET <br /> S� FA ILITY SITE NAME <br /> I FACIILLTT CONTACT NAME <br /> T <br /> c rr 1 I <br /> E FACIL! ADDRESS SITE PHONE S with AREA CODE <br /> & \IN5i S. 51 2a9 Yy /— y32'4- <br /> CITY C I STATE ZIP CODE Y of TANKS <br /> P. )"c,Ic 1\ -70 at SITE .3 <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT N ~y <br /> 2 Z.N.c. <br /> I SLD I 1.1 V, 4.. <br /> C MAILING ADDRESS 1 APP}(CANT PHONE B u H AREA (TIDE <br /> " a� C 9 <br /> , X023 - L��2 Ip <br /> 7 CITY �p tlpyjG STATE ZIP CODE TYPEosurr, Ins allation, etc.) <br /> /� 9 I�-�� <br /> TOTAL <br /> 1 <br /> ANNUAL FACILITY FEE (Prior Co January 1, 1991) 5100.00 1986 1987 1988 1989 1990 <br /> A x)ax XXXX xxxx )=X xxxx 5 X <br /> C I XXXXXXX <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I xxxx xxxx I XXXX xxxx I xxxx S XXXXXXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) I 5170/TANx (After January 1, 1991) <br /> E <br /> 3 Tanks = 1987 1988 1989 1990 1 1991 11992 11993 11994 11995 11996 11997 ! <br /> F (muleipty X by fee for <br /> A each year appticable) XXXX xxxx I xxxx M-X jxxxx I I I S <br /> I TANK PENALTY FEES ASSESSED XXXX I xM I xxxx I XXxx IXxxx I I I I I s <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES CULT = S18.50 ,S <br /> T <br /> T - Tanks, x $8.00 1988 through 1990 (S56) 1991 through 1996 (556) 1997 <br /> SURCHARGE FOR 1997 Xxxxxxx)XXXXXXxxxxxxx7IX%XXX XXXxXXX)OMXXXXXXXXXXXxx S I <br /> C PERMANE4T CLOSURE (Removal or Authorized Ctosure-in-Place) I TANK I.D. ;(s) 1 <br /> L 1 <br /> 0 CLOSURE FEE = 578.00/hour (3 hours mininAVTANK) 9 TANK(S) x 5234.00 5 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) i TANK I.D. il(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - S78.00/hour (3 hours minimmm/FACILItY) I 5234.00 minimum ; <br /> P INSTALLATION PLAN CHECK (Plan Revive. ; Gonctructian ItNspcetiwss) TANK I.D. B(s) I <br /> L <br /> A <br /> R PLAN CHECK FEE = 578.00/hour (8 hours minimun/FACILLTT) = $624,00 minimum S <br /> R REPAIR FEE (Workp(an Review & Construction Inspections) TANK I.D. 9(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) t TANK(s) X 5734-00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE - S78.001110ur (3 hours min-/FACILITY) S234,00 minimum <br /> R i S 2 L/ 00 <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78-00/hr I 5 <br /> 5 <br /> C CONSULTATION FEE_- S78.00/hr I SAMPLING INSPECTION FEE - S78.00/hr S <br /> TUTAL DUE b 2 3 L/ 0 O <br /> FOR OFFICE USE ONLY <br /> „d�IR tlwPmW mYtn^mSmmma:: <br /> SWEEPS Y I CONFUTER S LOC CODE I D[ST CODE AMOUNT RECE IVEO I CHECK X/CASH I RECEIVED B7 <br /> � DATE RECEIVED <br /> 5S5 — <br />