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2-19-1998 10-35AM FROM <br />° SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />` <br />UNDERGRMIND STS TANK PROGRA14 - FEE UORKSHEET <br />S <br />FACILITY SITE NAME <br />Q2- <br />FACILITY CONTACT NAME <br />-J-CliNoQ&s, '(`Ii0/rust <br />A <br />N <br />eAtcA i l Lib ® <br />5 <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = <br />'E <br />& <br />FACILITY ADDRESS <br />W cl,- "loo RC)OL tk. <br />SITE PHONE # with AREA CODE <br />Q Ca e( — L-1 (o D — -3 1®^i <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br />1986 <br />XXXX <br />1987 <br />1988 <br />1989 <br />A <br />P <br />CITY <br />�(� U� <br />STATE <br />�` <br />ZIP CODE# <br />Cj " <br />of TANKS <br />atSITE <br />XXXX <br />S XXXXXXXX <br />T <br />I <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />I <br />(� <br />XXXX <br />S XXXXXXXX <br />V <br />E <br />CC <br />A <br />MAILING ADDRESS <br />CA <br />APPLICANT PHONE # WITH AREA CODE g <br />5170/TANK <br />(After <br />January 1, 1991) <br />T <br />CITY <br />A,�% v`(� <br />STATE <br />ea <br />ZIP CODETaT( <br />4S-�DCtowre, <br />YPE Of APPLICATION n4`, Gc j <br />Installation, etc.) <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) <br />TANK I.D. #(s) <br />A <br />N <br />L <br />5 <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = <br />TOTAL <br />A <br />C <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br />1986 <br />XXXX <br />1987 <br />1988 <br />1989 <br />1990 <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />S XXXXXXXX <br />T <br />I <br />FACILITY PENALTY FEES ASSESSED Of AppticabLe) <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />S XXXXXXXX <br />V <br />E <br />TANK FEE _ $50.00/TANK <br />(Prior to January 1,1991) <br />5170/TANK <br />(After <br />January 1, 1991) <br />F <br />A <br />C <br />0 Tanks = <br />(multiply # by fee for <br />each year applicable) <br />1988 1989 <br />XXXX XXXX <br />1990 <br />1991 <br />1992 <br />1993 1994 <br />1995 <br />1996 <br />1997 <br />1998 <br />XXXX <br />XXXX XXXX <br />S <br />I <br />TANK PENALTY FEES ASSESSEDXXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />S <br />L <br />I <br />T <br />STATE SURCHARGE FOR NEW FACILITIES ONLY=S18.50 <br />S <br />T <br /># Tanks x 58.00 <br />SURCHARGE FOR 1998 <br />1988 through 1993 (S56) <br />1993 through 1997 (S56) 1998 <br />XXXXXXXXXXXXXXXXX)OO=XXXXX <br />XXXXXXXXXXXXXXXXXXXXXXX <br />3 <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) <br />TANK I.D. #(s) <br />A <br />N <br />L <br />5 <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = <br />$ <br />TANK I.O. #(s) <br />P <br />A <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br />S <br />I <br />R <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.O. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimumt/FACILITY) $234.00 minimum <br />S <br />P <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />5 <br />R <br />E <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.O. #(s) <br />P <br />A <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = S <br />I <br />R <br />TANK RETROFIT/REPAIR FEE = 578.00/hour (3 hours min_/FACILITY) = S234.00 minimum S (� <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $Z34.00 minimum S -- <br />TRANSFER FEE = S20.00 1 1 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />I <br />Cl CONSULTATION FEE = 578.00/hr I , SAMPLING INSPECTION FEE <br />FOR OFFICE USE ONLY <br />_.._ ___.._.. ._......... —.... <br />i�PSeiiil ='� fEciiiFir �i <br />SWEE# f COMPUTER # I LOC CODE 1 DIST CODE AMOUNT RECE <br />S <br />= S78.00/hr <br />—ice— <br />IVED BY I DATE RECEIVED <br />