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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br />MRGROUND STORAGE TANK PROGRAM - FEE WORKSHE� <br />S <br />FACILITY SITE NAME <br />FACILITY CiW <br />0.,ACT NAME <br />T <br />fiZ K Sto Q 0 A20 _ <br />A%GCG 11 Cl K. s1d�V <br />E <br />FACILITY ADDRESS <br />'�3 <br />SITE PHONE # with AREA CODE <br />& <br />'9 <br />CITYFes�T <br />TE <br />ZIP CODE <br /># of TANKS <br />XXXX <br />S O C C <br />at SITE oZ <br />IA* <br />$ <br />T <br />I <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />P <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />I <br />c'/Z /',17 <br />V <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />N <br />8 Y3 pyISke ,Lenc <br />C 3 — &8 <br />T <br />CITY <br />STAT174�:x <br />DE <br />TYPE of APP <br />1 1988 <br />(,l�L'S� S G <br />CA <br />(Closure, Installation etc.) <br />TOTAL <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />S <br />$ Z <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ XXXXXXXXXXXXX <br />A <br />C <br />$ <br />T <br />I <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ XXXXXXXXXXXXX <br />V <br />TANK FEE _ $50.00/TANK (Prior to January 1,1991) <br />$170/TANK (After January 1, 1991) <br />E <br /># Tanks = �/ <br />1986 <br />1987 <br />1 1988 <br />1989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1994 1995 <br />1996 <br />F <br />(multiply # by fee for <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX$ <br />cj <br />40 <br />A <br />each year applicable) <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ <br />L <br />I <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T <br />Y <br /># Tanks x $56.00 <br />1988 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />$ <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />C <br />CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE ='$78.00/hr $ <br />0 <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />S <br />$ Z <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />$ <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />C <br />CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE ='$78.00/hr $ <br />A <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum <br />$ Z <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />C <br />CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE ='$78.00/hr $ <br />P <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />A <br />I <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum <br />$ <br />R <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />$ <br />M <br />I <br />TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br />S <br />s:::::a:s::¢::sa::::t: s:s a:::a¢::::sa:: <br />AMOUNT RECEIVED <br />C <br />CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE ='$78.00/hr $ <br />TOTAL DUE $ / © <br />FOR OFFICE USE ONLY <br />:_::::: <br />SWEEPS # <br />[st::t::as::s:::[:::s t:::s:t::saa::: <br />COMPUTER # <br />_ ::s s:s: a c........... :::: assns:t:::::::st:;::s:: <br />LOC CODE DIST CODE <br />s:::::a:s::¢::sa::::t: s:s a:::a¢::::sa:: <br />AMOUNT RECEIVED <br />_........_..........._._......._..._...............................:...:..:::::::::::::::::::::::::: <br />=c w __.........._ ::_........................ <br />CHECK #/CASH RECEIVED BY <br />:::::.::::::::::::::::::::::::::::: <br />::::::;s: s;: :a::::s <br />DATE RECEIVED - <br />9 <br />