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bb/17/1998 17:38 209-825-4251 B/W INN OF MANTECA <br /> PAGE 10 <br /> SAN JOAQUIN A PUBLIC HEALTH SERVICES • ENVIRONMENTAL HEAL' <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> 3 FACILITY SITE NAME FA IIITY CONTACT NAME <br /> T — ticxv j c — ' U0 t� L _ a vuR.tAIJ <br /> 'E FACILITY ADDRESS SITE PHONE P With AREA CODE <br /> 31 14 S e v"rr .7 - - - z.3 -- <br /> CITY �A STATE ZIP CODE N of TANKS <br /> pli � -L-/ _ Jam% at SITE <br /> P APPLICANT/BILLING NAME I. APPLICANT CONTACT NAME <br /> e �1 L_ Cil . — (v Sid� <br /> C M ILiNG ADDRESS �7 APPLICANT PHONE N WITH AREA CODE <br /> T CITY STA E ZIP CODE iTvE of APPLICATION <br /> f'/"K _ V (Cl oaure, Inste uetlon, �g1HC-A�0!.` <br /> IE <br /> Lt <br /> '�l >�.,•�.,)� YI TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY ;(Prior ;(IfApp0csk;te) <br /> 1991) 2100.00AXXXX xxxx XXXX xxxx %XXX % KXxxxxxx <br /> GT FACILITY PENALTY Xxxx xxxx xxxx xxxx XXXX E xxxxxxxx <br /> tV TANK FEE • 550.0amary 1,1991) 3170/TAMC (After January 1, 1991) <br /> E <br /> Y Tanks • 9 1990 1991 1992 1993 1994 1995 1996 1997 1998 <br /> F (multiply Kbyby fA each yearapplicX xxxx I XX%% xxxx S <br /> L <br /> 1 TANK PENALTY FEES ASSESSED I XXXX xxxx xX%X xxxx xxxx I I 2 <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLYW 8.50 3 <br /> T <br /> Y Y Tanks_ x 28.00 �10XX�� (256) 1993 through 1997 (556) 1998 <br /> SURCNAgGE FOR 1998 %xx)Ox %XX%%%XXX%%%xxxx%X%%X%x E <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Platt) TANK 1,0. a(s) <br /> L <br /> 0 CLOSURE FEE a 278.00/hour (3 hours mi,i=AVTANK) a TANK(s)_ X 2234.00 x 2 <br /> S <br /> U <br /> RTEMPORARY CLOSURE (Plan ReVfm 7t Inspections) TANK I.D. N(s) <br /> E TEMPORARY CLOSURE FEE • 278.00/hour (3 hours mininAml/FACILITY) 2234-00 minimum 2 <br /> P INSTALLATION PLAN CHECK (Plan Review K CAnetructien Inspaetfons) TANX I.D. 0(s) <br /> L <br /> A <br /> N PLAN CHECK FEE • 278.00/110ur (8 hours minimus/FACILITY) • 2624.00 minima 2 <br /> IRREPAIR FEE (Workplan Review L Co(lstructioo Inepactiom) rANK 10X(S) <br /> NK LINING REPAIR FEE • 178.00/hour (3 hours minimus/TANK) a rANK(s) X 2234.00 • S <br /> NK RETROFIT REPAIR FEE N 278.00/hour (3 hours min./FACILITY) a 2274.00 mininam 1 <br /> PING It <br /> FEE 578.00/hour 0 hours MIMImun/FACILITY) • 2234.00 mini num S <br /> M <br /> f TRANSFER FEE • 220.00 I UNAUTHORIZED RELEASE EVALUATION s 578.00/hr I S <br /> 3 <br /> C CONSULTATION FEE = 378.00/hr SAMPLING INSPECTION FEE • 278.00/hr S <br /> TOTAL waE 2 Z <br /> FOR OFFICE USE ONLY <br /> x�anllGrmmfl;n :iml.:wl .r -.:u.em�miml��s�lcjwmo :;:�_.,.:�,� +e�ruwuna IntmrAlr r n .mtnulanaumJmnnwm n^ lmnumm�nwumnnll r. <br /> SWEEPS a I ww::d.: w.::.:ww:s,.l.na...r.aar�wuwlu�oln,nn�.ccu.' i t vw ru.l,miu L.-.��... I I un��Cl I <br /> COMPUTER a I LOC CCOE 01ST CODE I AMOJNT RECEIVED I CHECK Y/CASH RECEIVED BY i DATE RECEIVED I <br /> � I I <br /> I .mmmn! mw:nr_rae!e�!IlerlmsmnlIryry 6 Ir+m2ryI �� <br /> INTI IUmNmUUUWImkUIImUUIII ��I aala m•�' �£i:��� .. ��wmulnnUllllminldmnR�mTr']nilGlry�gnl II�mOnimlln limn <br /> d5:1" :AEWY.iE6-1i:� mll VIJIIAtl®n YIIIN J "nW:G1;�IWItlI000YY�--:WU1M�n 11Jl.i,>v..:: <br /> EN 23 G32 (REVISED 1-'2.98) <br /> JUN-17-1998 17:23 209 1325 4251 96% P. 10 <br />