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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />OFFICE USE ONLY <br />E4 23 032 [REV 1/10/91) ft Paoe 11 <br />FACILITY SITE NAME <br />TANK I.D. #(s) <br />FACILITY CONTACT NAME <br />F <br />C <br />/%P�/ C <br />S <br />Ing 1"4VI/ <br />S <br />U <br />TEMPORARY CLOSURE (A one-time permit, for review/inspections) <br />TANK I.D. #(s) <br />I <br />FACILITY ADDRESS <br /># TANK(s) X $150.00 = <br />SITE PHONE # with AREA CODE <br />L <br />P <br />PLAN CHECK (Install. Plan Review & Construction Inspections) <br />T <br />Y <br />CITY <br />5 p <br />STATE <br />CA <br />ZIP CODE <br />�O V <br />of TANKS TN%a — A?1*4-lq <br />f1TpMks <br />at SITE Q,fQ QQdYl0 a 0 -cc <br />A <br />P <br />P <br />L <br />APPLICANT/BILLING NAME <br />t <br />REPAIR FEE (workplan review & construction inspect i ors) <br />APPLICANT CONTACT NAME <br />2abb s i5e.Y-�. WLoveiw <br />E <br />P <br />TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br /># TANK(s) X 5159.00 = <br />$ <br />I <br />A <br />MAILING ADDRESS <br />u��� oH` <br />rZ0 <br />APPLICANT PHONE # WITH AREA CODE t <br />-3 -7 ,70 <br />N <br />CITY <br />STATE <br />ZIP CODE TYPE of APPLICATION R E TES 7— <br />T <br />e <br />RELEASE EVALUATION <br />CLOSURE, INSTALLATION, etc. <br />C <br />FFEE = 553.00/hr <br />FEE = 553.00/hr <br />TOTAL <br />FEE = S 53.00/hr <br />A <br />S <br />C <br />1986 <br />1987 <br />1 1988 <br />1989 <br />1990 <br />T <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 8100.00 <br />$ <br />1 <br />V <br />E <br />TANK FEE = 550.00/TANK (prior to January 1,1991) <br />8170/TANK <br />(after <br />January <br />1, 1991) <br />F <br /># Tanks = <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />A <br />(multiply # by fee for <br />S <br />C <br />each year applicable) <br />I <br />L <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />I <br />T <br /># Tanks x S56.D0 <br />1986 through 1990 <br />1991 through 1996 <br />Y <br />(enter anant and year) <br />S <br />OFFICE USE ONLY <br />E4 23 032 [REV 1/10/91) ft Paoe 11 <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />C <br />L <br />CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) <br /># TANK(s) X 5159.00 = <br />S <br />0 <br />S <br />U <br />TEMPORARY CLOSURE (A one-time permit, for review/inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $150.00 each TANK <br /># TANK(s) X $150.00 = <br />$ <br />P <br />PLAN CHECK (Install. Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />ALAN CHECK FEE - $53.00 per hour (8 hours mini num per Facility) = 5424.00 mini mm <br />5 <br />R <br />REPAIR FEE (workplan review & construction inspect i ors) <br />TANK I.D. #(s) <br />E <br />P <br />TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br /># TANK(s) X 5159.00 = <br />$ <br />A <br />I <br />R <br />PIPING REPAIR FEE = 553.00 per hour (3 hour minimum per facility = 5159.00) <br />5 <br />M <br />I <br />S <br />CONSULTATIONSUNAUTHORIZED <br />RELEASE EVALUATION <br />SAMPLING INSPECTION <br />3 hr m,n <br />C <br />FFEE = 553.00/hr <br />FEE = 553.00/hr <br />FEE = S 53.00/hr <br />TOTAL DUE <br />S <br />OFFICE USE ONLY <br />E4 23 032 [REV 1/10/91) ft Paoe 11 <br />