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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM -FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONT CT NAME <br /> I (6l P er <br /> T <br /> E FACILITY A9Qa6RESS n ITE PHONE # with AREA CODE <br /> ( QLtvt�Y ZNI) 9Fs2--b'A?_ 7 <br /> A CIT ;7975 �S CODE <br /> at SITENK5 <br /> P (; btn ll l�k <br /> P APPLICANT/BILLING NAME APPLICAN CQN CT NAME <br /> L SEA(Cf7 HMI 3uI <br /> I <br /> C MAILING ADDRESS r, APPLICANT PHONE # WITH AREA CODE <br /> M W-7 S . 7 i Lu(- ;"3 <br /> i C(T STATE 2 P CODE TYPE of APPLICATION <br /> %Ll0(jP�Ea 64 S35 I (Closure, Installation, etc.) IZ¢aAaVG <br /> TOTAL <br /> A TANK FEE = 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> C <br /> T # Tanks El9X86 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> I (multiply )-5y—fee for <br /> V each year applicable) X xxxx xxxx xxxx xxxx S <br /> E <br /> TANK PENALTY FEES ASSESSED XXXx xxxx xxxx xxxx xxxx $ <br /> S <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California N 8 S Code, Section 25287 <br /> T <br /> E # Tanks z $56.00 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. #(s) <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) L % $234.00 = S LIV <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.O. 1i(s), X <br /> R I.��d/,t`Ii 70Z. 00 <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review B Construction Inspections) TANK I.O. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) $624.00 minimum E <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.O. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) x $234.00 = s <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimun/FACILITY) = $234.00 minimum s <br /> NJ TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION - $78.00/hr S <br /> 1 <br /> S <br /> C CONSULTATION FEE = E78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr S <br /> TOTAL DUE CIO <br /> .RFOR...O.F..F.LGE.,USE._.QN.IT:_--_ � ---- <br /> ::_:_::_:::.:::: _::_:::�:_:......._-mom..._.:__,.,.._.._:_.:,.,..._.. ...�,._..::_-_T_ .r=_ :.��::a=:.._--.__..:_-'_-'--__::.__ .... - - --- - <br /> ._..... ._......................_._..._.__............,,-:-_:-rte,.,-::::�=:,. _.._ :::--.,,_-.__.....:-_::_::_:::::::z..,-„ =_ _""- - - -- - - <br /> ...... .....:...:..�.................. ......._............... .. _._.�:: ....._.. ::::-.m -_: _�... .. <br /> mf..u?..... ....... .. _ 9 3& .._....._ J Fm::c::::::_3.4aaan::c....,,�1 x......iR:.2e.__...._.P:[p:...nasi:::ffif2f:!v::f::.:i.lta::3�:1 <br /> SWEEPS #'-...�Z�Dri�PUYr:'k�–#-'i'a3�b2 tDDE �'�SItY C6D��''AMaiNT k"ECE�IVED' rCNEC�#7�Cb�5�H �`-`"kECEIVED-8P �""`DAYERECEFVEIS....—;� <br /> �menumvnnma::miE....._. :::o: mme::a::::.^...:."^.^=.'^:mn-.n=,...:vem-m��:mam�av5.x!._..� -P.-anT'e..._.^�^'. .m^ - _.=_�.m.q!�_.-.,.:n::^€=.[in <br /> gas:.==ai_��_=:t :-��=ear..... _..._ <br /> EH 23 046 (Revised 7/10/96) Page 11 <br />