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12/18/98 FRI 09:35 FAX °'16096304 RHL DESIGN GR011^ RHL PETALUMA Q014 ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET S FACILITY SITE NAME FACILITY CONTACT NAME I cy-f-\L �RETT NoVLi�NO T — E FACILITY ADDRESS SITE PHONE I with AREA CODE -r -o ClNatrAer WCL14 925-157-1995 CITY STATE ZIP CODE 9 of TANKS A SToC-kTOIJ lcA 9 5,zos at SITE P P APPLICANT/BILLING NAME APPLICANT CONTACT NAME I � , \ g� xS$s BR =TT Ho\[LwnD F- - C MAILING ADDRESS APPLICANT PHONE 4 WITH AREA CODE A ' C) x 1S C)$D OtZS- 757- 1955 N T CITY STATE ZIP CODE TYPE of APPLICATION 9y 553 (Closure, Installation, etc.) C,I(ISWe TOTAL 1986 1987 , 1988 1989 1990 ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 A XXXX XXXX I xxxx I XXXX XXXX 5 XXXXXXXX C T FACILITY PENALTY FEES ASSESSED (If AppLicable) XXXX I XXXX XXXX XXXX xxxX $ Xxxxxxxx I V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) E A Tanks = 1988 1989 1990 1 1991 11992 11993 1994 1995 11996 11997 1998 F (multiply # by fee for A each year applicable) xxxx XXXX xxxx xxxx Ixxxx I S C 1 TANK PENALTY FEES ASSESSED I XXXX xxxx xxxx XXXX (XXXX , f I 5 L I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 5 T Y T Tanks x $8.00 1988 through 1993 (5556) 1993 through 1997 ($56) 1996 SURCHARGE FOR 1998 xxxxxxxxxxxxxxxxxxXXXXXXXXX XXxXxxxxxxXxxxxxxXXXXXX 5 C PERMANENT CLOSURE (Removal or Authorized Ciosure-in-Place) l TANK I.D. $(S) L l -- OI CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) I 0 TANKCS) It X 5234.00 = S ?J 6 po S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. x(s) R E' TEMPORARY CLOSURE FEE - 978.00/hour (3 hours minimum/FACILITY) 3234.00 minimum S Pi INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK S.D. V(s) L A N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum 9 R REPAIR FEE (Workplan Review & Construction inspections) I TANK I.D. I(s) E P TANK LINING REPAIR FEE = S78.00/hour (3 hours Minimum/TANK) S TANK(s) X 5234.00 s A I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234-00 minimum S R PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ M TRANSFER FEE $20.00 i UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I S I 1 S j C CONSULTATION FEE = $78.00/hr f SAMPLING INSPECTION FEE = 578.00/hr f S TOTAL DUE S FOR OFFICE USE ONLY ....... —__....w,._MS.: -...........-_...........__..-_.__3....._-�...._...:._....z.-..._....nt...1h........_-._....._»._x..-.-a99?^?. �t--i...r.-._..rssx---^a.:�=.��•M'�^_.^_."iuuli3zz'i}"i� . r..:= ----' a'-'[:-•Y-'mss`=.ii:-«-.- ....._»•s..•�:::.:_c::t:Silt-:,.°.�S:::s:cz�•'iQ.3351Atl!!C[!L'°".!_....•- �•�zcs"7 •�:uii�•"-.:_.._:a:...»•- :n SWEEPS COMPUTER LOC CODE I DIST CODE AMOUNT RECEIVED I CHECK ;*/CASHRECEIVED BY DATE REC=-T.VED i - - - - - - L'::.�. :::...._•«._................................_._......__..._.._._...P•::[:isL•:i�:.^:�:nnt�.Y.:.^.::::::T..t:: ^:t.T......:r:::.'��::�Y^.::[f:.Wt::��::i:::..��'�'�:.�'�::F�:= _ _ _— _ _ —� _ _ .. ..........»t_..1......._.....�.....t........_.................._. r_:C3��1'�LtEl:. n wr xzuu•z....-.t.,.«.a.,_,......t..y....._-.._...._._...>=-tn:t-•c-..-........_...:«..-..._..._._...,...�......._t_—__.__.._.. ...............yv-.- .t1L-'hII.J»i. ....._.zrsu��::w.:»::.-..::-.::._�::°c - -:_...::_--- -._.__ .a•.:rac:ezza[u°z+ ��-•-•--_- ..r rM 7-N n-i? (RFVtSF❑ 1-12-98)