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• L'"GCJ r&":10 r I !uyNNl rRUi 7 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - tMR0II11E11TAL NEALTN DIVSJON <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY ITE NAME fACIL[TT CONTACT NAME <br /> I c..Y, C V r &J4 <br /> - T <br /> 'E FACILITY ADDRESS SITE PHONE S with AREA CODE <br /> tj <br /> CITY �'+ 0 c �� / STATE ZIP CODE atpSITENKS <br /> A V <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> t <br /> C MAILING ADDRESS APPLICANT PHONE E WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYP APPLICATION <br /> (Closure Installation, etc.) d. ) luiC <br /> TOTAL <br /> 1986 11987 1488 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 3100.00 <br /> A XXXX xxxx XXXX XXXX XXXx S xxxxxXxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX xxxx XXXX XXXX XXXX S xxxxxxxx <br /> V TANK FEE $50.00/TANK (Prior to January 1, 991) 5170/TANK (After January 1, 1991) (� � <br /> E <br /> M Tanks = 1988 1989 1990 1991 1992 1993 1994 19951996 1997 1998 U' <br /> F (multiply X by fee for <br /> A each year applicable) xxxx + xxxx XXXX XXXX xxxx 1'7 0 b I170 O 76 3 10 Q• <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx XXXX I xxxx xxxx D 611701 Q v _ <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY-518.50 <br /> T <br /> Y S Tanks--L x $8.00 1988 through 1993 (1556) 1993 through 1997 (1556) 1998 <br /> SURCHARGE FOR 1998 xxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx 3 ''- <br /> 0 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK t.D. 9(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour d hours minimum/TANK) ( x TANK(9) i X 5734.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review i Inspections) TANK t-D, d(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILiTY) $234.00 minimum f <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. 9(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review i Construction Inspections) TANK I.D. As) <br /> E <br /> P TANK LINING REPAIR FEE = =78.00/hour (3 hours minimum/TANK) Ik TANK(s) x S234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 378,00/hour (3 hours min./FACILITY) = 5734.00 minfix S <br /> R <br /> PIPING REPAIR FEE a $78.00/hour (3 hours minimum/FACILITY) _ 1234,00 minimum IS <br /> N TRANSFER FEE a $20.00 UNAUTHORIZED RELEASE EVALUATION n 578.00/hr + 3 <br /> I I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 378.00/hr S <br /> TOTAL DW $ <br /> FOR OFFICE USE ONLY <br /> s^z�_._ ---�,c a a,mmn:r +nm!n!ntl1!nNmnnm1191mm911nL�gMnp11 !nnnmlmllll:nn�lnim:m!r.!nl!nn0valln!m!rrawliqMRIMa;t7""NOR <br /> !mrlt <br /> g71Upy!DI (11',+,1(i�•—•Y^=:�==-'~'•'i.=_�a7r-xvn»cn�::i:'F"a+_.--��':-"Gi«l�ieili6�i'ruri�aiirc.�'rw�_r.:c.ec:n�willin'limlw—i—iNfei'�i it•�--='e'^'E—�=:+ci'"�+"'�'.innilitl{III»ii.a!ghl�Ull�l�ia�_. <br /> SWEEPS 9� COMPUTER X LOC CODED IST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED = <br /> a' <br /> Cv rte :—,,�,,^ "_:•_'•.: :».:.•aczrs=:cZ:.miN1!5!1 !!1@R!.7MJ0T!+"..i IF. 'i!r.11111!tln JILR^t^!1!nllnmUGMgI .Ildl!1111nIYm!IfilglhllfiMifilgl <br /> ;�m�l IL01!I:MtRilnhtWlagtKin!6 aq!nY t J« —ice===- — •= rglL�. -- i�9!ILo�»c <br /> f` <br />