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7-1999 9:40AM FROM P- 9
<br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION
<br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET
<br /> S FACILITY SITE NAME FACILITY CONTACT NAME
<br /> C -LCL
<br /> !: FACILITY ADDRESS I SITE PHCNE # with AREA CODE
<br /> & �to ` c� �ju.)• �. �.•;.� c'\3�— S�
<br /> CITY STATE 71P CODE # of TANKS
<br /> Al C1" at SITE
<br /> Pf —
<br /> P1 APPLICANT/BILLING NAME APPLICANT CONTACT NAME
<br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE _
<br /> r� N
<br /> it T CITY �. STA;"ei ZIP CODE TYPE of APPLICATION
<br /> (Closure, Installation, etc.)
<br /> TOTAL
<br /> 1986 # 1987 1988 1989 1990
<br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00
<br /> A xxxx I xxxx xxxx xxxx xxxx $ xxxxxxxx
<br /> c
<br /> T FACILITY PENALTY FEES ASSESSED (If ApplicablC) XXXX xxxx xxxx XXXX I XXXX 3 XXXXXXXX
<br /> I '
<br /> V, TANK FEE = $50.00/TANK (Prior to January 1,1991) { S170/TANK (After January 1, 1991) ^'
<br /> E
<br /> Tanks = 1988 1 1989 1990 1991 1992 1993 E 1994 1995 11996 i 1997 1 1998
<br /> P (muttipty T by fee for
<br /> Ai each year appticable) XXXX xxxx xxxx XXXX XXXX ( S
<br /> C"
<br /> II TANK PENALTY FEES ASSESSED ! XXXX xxxx XXXX l XXXX XXXX 1 I $
<br /> L
<br /> II STATE $URCHARG"c FOR NEW FACILITIES ONLY=518.50 $
<br /> T w
<br /> „ YI # Tanks x 58,70 1988 .hrougn 1993 ($56) 1993 through 1997 ($56) 1998
<br /> I SURCHARGE FOR 1998 xxxxxxxXXXXXXXXxxxxxxxxXxxx XxxxxxxxxxXxxxxxxxxxxxx
<br /> I
<br /> CPERMANENT CLOSURE (Removat or Author.Zed Ctosure-in-Plate) TANK I.D. #(s)
<br /> L;
<br /> 0; CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) A! TANK(s) X $234.00 = $
<br /> S•
<br /> Ul TEMPORARY CLOSURE (Plan Review & Inspections) 1 TANK I.O. #(s)
<br /> R'
<br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $
<br /> Pi INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s)
<br /> L.
<br /> A
<br /> N, PLAN CHECK FEE = S78.00/hour (8 hour: minimum/FACILITY) _ $624.00 minimum $
<br /> Ei REPAIR PEE (Workplan Review 3 Construction Inspections) I TANK I.D. d(s)
<br /> P TANK LINING REPAIR FEE a 378.00/hour (3 hours minimum/TANK) # TANK(s) X $234,00 = $
<br /> A
<br /> I TANK RETROFIT REPAIR FEE _ S78.00/hour (3 hours min-/FACILITY) = 5234.00 minimum S
<br /> R
<br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/=ACI LI TY) = SZ34.00 minimum $
<br /> M1 TRANSFER FEE = S20.00 f ` UNAUTHORIZED RELEASE EVALUATION = S78.00/hr $
<br /> S� I I 1
<br /> C CONSULTATION FEE _ $78.00/hr I SAMPLING INSPECTION F"sE = S7S-OO/hr 5
<br /> TOTAL DUE $
<br /> FOR OFFICE USE ONLY
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<br /> ! LOC CODE ! DIST CODE i AMOUNT RECEIVED � CHECK #/CASH I RECEIVED SY DATE RECEIVED
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