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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> /ACFACILITYS17EME FACILITY CONTACT NAME <br /> -M '11 r !� N �IAADDRESS SITE PHO"r INE N with AREA COD• ' <br /> 3 fF � </ 33 a'v4- 835-o7R38 <br /> A STATE 21P CODE N of TANKS <br /> CITY <br /> A CH• 7537/0 at SITE VA.)E RECEIVED <br /> P APPLICANT/BILLING ME APPLICANT CONTACT NAME JAN 1 1 1999 <br /> L �q,W E AS ABoJE <br /> I APPLICANT PHONE N WITH AREA MBLIC 1{F.ALTFI AERVIC i <br /> C MAILING ADDRESSLHEALTHDI ENVIRDNMENTAS <br /> A <br /> R STATE i1�::!xi TYPE of APPLICATION p <br /> I CITY (Closure, lLICATlatlon, etc.) REM01/A L <br /> TOTAL <br /> 1986 1987 1988 1989 , 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 ! <br /> A <br /> C <br /> T xxxx xxxx 9 <br /> FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I 9170/TANK (After January 1, 1991) <br /> VTANK FEE * 950.00/TANK (Prior to January 1,1991) <br /> E p Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> v <br /> F (multiply fee for ^ 9 170.00 <br /> A each year apptieable) <br /> C s <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx <br /> L <br /> 1 STATE SURCHARGE • 956.00 each TANK (Due every 5 years) See Callfornia N 6 S Code, Section 25287 <br /> T1991 through 1996 <br /> Y N Tanks x 156.00 1986 through 1990 <br /> (Enter amount find year) ! <br /> C PERMANENT CLOSURE (Removal or Authorized C(osure-in-Plsca) TANK I.D. N(a) - OO <br /> L N iAHK(a)� X 9234.00 • : ,'� <br /> 0 CLOSURE FEE • 178.00/hour (3 hours minfmum/TARK) <br /> STANK I.D. N(s) <br /> U TEMPORARY CLOSURE (Plan Review t Inspections) <br /> Rt <br /> E TEMPORARY CLOSURE FEE • 978.00/hour (3 hours minim:m/TANK) N TANK(fl)_ x 9234.00 = <br /> P INSTALLATION PLAN CHECK (Plan Revlew A Construetton Inspections) TANK I.D. N(s) <br /> L <br /> A = 9624.00 minimum <br /> = <br /> N PLAN CHECK FEE • 978.00/hour (8 hours m(nlaWFACILITY) <br /> R REPAIR FEE (Workplan Review 6 Construction Inspections) TANK I.D. N(a) <br /> E <br /> P TANK LINING REPAIR FEE • 918.00/hour (3 flours minimum/TANK) N TANK(s) x 9234.00 = <br /> A 5234.00 minimum S <br /> I TANK RETROFIT REPAIR FEE a 978.00/hour (3 hours min./FACILITY) <br /> R . 9234.00 minimum s <br /> ' PIPING REPAIR FEE • 978.00/hour (3 hours mfnfmum/FACILITY) <br /> N TRANSFER fEE • 920.00 UNAUTHORIZED RELEASE EVALUATION = !78.00/hr S <br /> 1 <br /> S 9 <br /> C CONSULTATION FEE = 978.00/hr SAMPLING INSPECTION FEE = 978.00/hr <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY i i mn nnm I'll, <br /> u: i qip:nm n m:mmt lmm�i� �m il�m�domn,nnrc�iq�i�mnlu!nm!��pniKimnx�nml�l!!IpJ�gvj "m:!"IhI!3!I" !:";!I,��;r.: <br /> If{�i!:'� n�1 9pL=5:.n�°lIM in :I!1�:��(!9�:�1��7C!�a�man!I !I:JI!!,N 9F .:Ilrilr!m111M�!n aa.1,. m i 9�arr.. <br /> SWEEPS N COMPUTER N LOC CODE DIST C00E AMOUNT RECEIVED CHECK N/CASA RECEIVED BY UAtE RECEIVED <br /> M RR ni IN�l�ll!"!I! IIP I LNifi l!IP! {!I!!!ml�"RP kI" "C!I!!!'.I P10.0�9!9 0 i!!!!!C!TUN!010011 R!C!!I��!!k!. . :. :..m::::8h n..:: :,,""::::.�Fmi�� <br /> ? ,(mange 11 <br /> EH 23 032 (REVISED 11-1-92) / h� IV(� <br />