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3 <br /> SAN JOAQUIN OTY PUBLIC HEALTH SERVICES - ENVIRONMENTA*LTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> * <br /> FACILITY SITE NAME ( FACILITY CONTACT NAME <br /> I 7'q y s r�I I N I r�A(Zi�-E T <br /> T . I SITE PHONE # with /AREA CODE/- <br /> E FACILITY ADDRESS 33Oo WEST LAA)e to i — <br /> STATE ZIP C E # of TANKS <br /> CITY STQL -rte• I G�t c1 �/ at SITE 2 <br /> A �V fc7 <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L �A MA9 Mc ILRAT4 LE€ a16-3�3�I16Q� <br /> C MAILING ADDRESS APPLICANT PHONE X WITH AREA CODE <br /> A l q p5 A14V M E Za`1 - lk,-L — 5T 07 <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION ►N TA C,14Tio <br /> 5Tp Ck'-ro rj 6j G7,Q(, (Closure, Installation, 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 I XXXX XXXX S XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX S XXXXXXXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> X Tanks = �' 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1997 Ind,*D <br /> F (multiply # by fee for S <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX 310.av <br /> C S <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX <br /> L <br /> I STATE SURCHARGE = S $.00/TANK L^v+04 1 <br /> Y 418.5''0/FAC IL11Y5-�- <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) X TANK(s) X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. X(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) S234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum FS <br /> R REPAIR FEE (Workplan Review b Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE s q q 8, so <br /> FOR OFFICE USE ONLY _ <br /> ......;....;..::•a::ss•:^r_c••:•��:•;,....:a::»».-.^"--::n:r.�:s«:rs u:::„'c::...^rr•••s:::.r..«•:usr..:t gun._.:-�sr.:aaaa:;sf:.• _�....�......_._.r. . �_ --ti:::�^.^i<^:::i:s�:i.'.�:i»ic:i:r�i•nx'^+=•.:.. <br /> ._....._..»..•::a.:?.a..:_».a:r:=.. .....:..:: a ..: �..u_:.3:F :mss._ ha:�r•ra <br /> - SWEEPS # I COMPUTER # LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK #/CASH I RECEIVED BY DATE RECEIVED <br /> S - <br /> M <br /> :._.._.:..........:..........................................:.._...:.... ._.._..�:_.:_..._ �..._...._....._.._.._..._-�7 M-- -._..._..._......_..._._.__ _ __ .._... <br /> _....__........................................................... ...._::::_ :-::_.-•:•::: <br /> REVISED . n3 5VO4C 'q� <br />