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SAN JQAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> IRm c. Ltye . <br /> T <br /> 'E FACILITY ADDRESS Sfft'PHONE # with AREA CODE <br /> i <br /> &I <br /> i CITY STATEI ZIP CODE # of TANKS <br /> A /4 at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L A/ Y _ S- <br /> I <br /> Cl MAILING ADDRESS. ,, � APPLICANT PHONE # WITH AREA CODE <br /> A17C) <br /> Tj CI. SjpTE ZIP CODE TYPE of PPLICATION <br /> (1)/4 9 v�2 os re, nstallation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A xxxx xxxx xxxx xxxx xxxx 5 xxxxxxxx j <br /> C <br /> TFACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX <br /> I <br /> Vi TANK FEE = $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1988 1989 i 1990 11991 1992 11993 11994 1995 1 1996 1997 1998 <br /> Fmulti lY # <br /> Y b fee for <br /> ( P <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX I $ <br />� C � <br /> I TANK PENALTY FEES ASSESSED XXXX I XXXX XXXX_j XXXX XXXX I I I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 $ <br /> T <br /> Y # Tanks x 58.00 1988 through 1993 (S56) 1993 through 1997 (856) 1998 <br /> i <br /> SURCHARGE FOR 1998 XXXxxxxxxxxXXXXxxx)mxxxxxx XXXXXXXXXXXXXXXXXXXXXXX S <br /> Cl PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> L <br /> 01CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s). X $234.00 = $ �� 0 <br /> S <br /> UTEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) I $234.00 minimum 5 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum is <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimun/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum S <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr $ <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> EH 23 032 (REVISED 1-12-98) <br />