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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONII7ENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM -FEE WORKSHEET <br /> I FACILITY SITE NAME FA�C�IL k C NT C rNAME <br /> E FACILITY ITE PHONE # with AREA CODE <br /> >< <br /> 2b$( ( Ow1 l�u� 2 A) 9FSL U' IZ'7 <br /> C[T $TATE ZIP�S CODE <br /> #tof <br /> TENKS Z <br /> At_.L C7V� <br /> ` APPLICANT/BILLING NAME AKIN CANT, NFACT NAME <br /> I ' EFIZ 1� J <br /> El NAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A fz(Z $ . JT, VZ - S3 <br /> T CIT JJ,�,, STATE ZIP CODE TYPE of APPLICATION <br /> O(jK b�a 531 1 (Closure, Installation, etc.) QeVi DVGt <br /> TOTAL <br /> A TANK FEE = 250.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> T # Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> I (multiplyyil y-fee for <br /> V each year applicable) %%%X XXXX XXXX %XX% XXXX $ <br /> E <br /> TANK PENALTY FEES ASSESSED I XXXX I XXXX %XXX XXXX XXXX S <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> E # Tanks x S56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. 0(s) <br /> — <br /> L <br /> CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) L X $234.00 = S y( .ov <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.O. #(s)� I. ,�,t`li 7 OZ, O <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum <br /> PI INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours miniaxm/FACILITY) = $624.00 mini mm S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.O. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimS <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum 3 <br /> M TRANSFER FEE = f20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> 5 <br /> C CONSULTATION FEE f78.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE <br /> ._.F(Xt O.F..FLCUS.E-ONLT..::: _. <br /> SWEEPS #'""�'OMPUTE�d�I-��O�C�6D.E_.:(tiBY-81%. 'anauNY REcETVED.._�-cA'E"c'K�FTCA's'il—�E'CE7YE6 9y—�—"0"A'TE R'ECEtVEti <br /> i 5 <br /> EH 23 046 (Revised 7/10/96) Page 11 <br />