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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> + UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAM <br /> I A T- <br /> T <br /> IL_Cy <br /> T <br /> E FACT ITY ADD ESS SITE PHONE N with AREA CODE <br /> iIr — <br /> i9n Owl "g- <br /> CITY STATE ZIP CODE N of TANKS <br /> A at SITE <br /> P <br /> P APPLICANT/91L 1110 APPLICJANT CONTACT NAM ,f <br /> 1-�U1 ! /4CI "'On-f f,0ALL, <br /> C NAILING ADDRESS APPLICANT PHONE E WITH AREA COOP <br /> N b 4163 2- 11 15- <br /> I CITY Si TE ZIP CODE TYPE of AOLICATION 11,/.4-a— <br /> ), (Closure, Installatlon, etc.) <br /> � TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991} '11---AO <br /> A <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (It App(leabte) XXXX X7(70( ! <br /> l .. <br /> V TANK FEE a 150.00/TANK (Prior to January 1,11) 070/T)kNK (After January 1, 1991) <br /> E <br /> R Tanks + 1986 1987 1988 1989 1990 1491 1992 1993 1994 1995 1996 <br /> F (mutttpty rwfea for <br /> A each year opplltobte) s <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX ! <br /> L <br /> 1 STATE SURCHARGE + 156.00 each TANK (Due every S year$) See Cattfornia H A S Code, Section 25287 <br /> T <br /> Y s Tanks it 156.00 1986 through 1990 1991 through 1996 <br /> (Enter Whxmt and year) <br /> ! <br /> C PERMANENT CLOSURE (Removal or AUtherlled Ctoaure-in-Ptece) TANK I.D. S(!) <br /> L <br /> 0 CLOSURE FEE * 17A.00/hour (3 hours ntlniftNTANK) ! TANK(s) X !234.00 ■ ! <br /> S <br /> U TEMPORARY CLOSURE (plan Revtev & Inspoetlons) TANK t.D. R(A) <br /> R <br /> E TEHPORARt CLOSURE FEE a 178.00/h6ur (3 houra mtnimWFACILIIY) a 1234.00 Islnlaua ! <br /> P INSTALLATION PUN CNECtC (plan Rdvlav ! Conatructlon ird plctlons) TANK I.D. S(s) <br /> L <br /> A <br /> N PUN CHECK FH l+ l78.00/hour ($ (tours minimunVFACILITY) 3624.00 Mlnimun ! /` <br /> R REPAIR FEE (1lerkptan Revlav 3 Construction inspection$) TANK I.D. Sts) <br /> E <br /> P TANK LINING REPAIR FEE a 178.00/hour (# hours minlmum/TANK) R TANK(s) X !234.00 = f <br /> A <br /> I TANK RETROFlt REPAIR FEE a l7S.00/hour (3 hours min./FACILITY) * !234.00 rMlnimua t <br /> R <br /> PIPING REPAIR FEE * 08.00/hear (3 hourt minllnwFACILITY) a 1234.00 mini" ! <br /> M TRANSFER FEE * S20.00 UNAUTHORIZED RELEASE EVALUATION a 978.006r ! <br /> I f <br /> S <br /> C COHSULTATIOM FEE' a 17$.00/hr SAMPLING INSPECTION FEN: a 17$.00/hr <br /> TOTAL DUE s <br /> FOR OFFICE USE ONLY <br /> si►nnr^S�FiiiilAij_ Jt�114r"n�'w" «�w.r»wrwia�» .»u�.rw.nw3w►�i.�i►»wi►ww�i«N»»»w.»'T.ur"Y.�iss�.�ii»�n�i►rw..nrwi iww»i^www.wr:►rr..ww <br /> 1 <br /> 3 9 s <br /> r.w+w.rww iii rww www wwrrwrwwrwrwwl:wwwwww'i►wwlr ww ww.r wwtww► ww ww ww►iw www iwifii�w ww iwe Mwn 'owii► wwwwfM:r iw www w►r ww Www www.s <br /> 11i 11$11rl MrlMt!<w MlMrMrMIM 11R�Mi lIM>r11W MMi �M4 MY1 rplhli AlNlfl lMMrINrIirMMwfMM 11MMr/NMr1M IMM `R A%wx4A ww*www lM1 ■MKlM 111/MMw IN AM <br /> EH 23 032 tREVISED 3-1-43) <br />