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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F ) <br /> FACILITY SI TE�7�f1E FACIL I7Y CONTACT HANE <br /> am ��s ro <br /> FACS llAOD RES!e _v� SITE PHONE 1< with AREA CODE <br /> T CITY [[JJCLU SlJITE 21P CODE 1 of TANKS J <br /> Y O L / <br /> et SITE <br /> A APPLICANT/BILLING NA/M1�E " APPLICANT CONTACT NAME <br /> 1 MAILING ADDRESS APPLICANT PHONE A WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE IIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> I f <br /> Y <br /> E TANK FEE 550.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F A Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply fee for <br /> C each year applicable) $ <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H d S Code, Section 25287 <br /> i g Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter unt and year) cv f 5�0 <br /> PERMANENT CLOSURE (Removal Or Authorized Closure-in-Ptace) TANK I.D. !(a) <br /> C <br /> U CLOSURE FEE = $53.00 per hour (3 hours minimun per TANK) k TANK(s)_ X $159.00 • S <br /> 5 <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. !(a) <br /> R <br /> E TEMPORARY CLOSURE FEE = 1150.00 each TANK A TANK(s) X $150.00 f <br /> P PLAN CHECK (Install. Plan Review d Construction Inspections) TANK I.D. #(a) <br /> L <br /> A <br /> .. N PLAN CHECK FEE - $53.00 per hour (8 hours mini mm per Facility) = $424.00 mini mm $ <br /> E REPAIR FEE (workp(an review d construction Inspection) TANK I.D. !(a) <br /> P TANK REPAIR FEE v $53.00 per hour (3 hours minim WTANK) R TANK(s) _ X !159.00 = 2 <br /> A <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility = $159.00) $ <br /> 1 TRANSFER FEE v $20.00 UNAUTHORIZED RELEASE EVALUATION v 153.00/hr f <br /> S <br /> ClCONSULTATION FEE a $53.00/hr SAMPLING INSPECTION FEE _ $53.00/hr $ <br /> TOTAL DUE <br /> =Man Q; ;: u � mmmimeeamma==�meommi ,.,my,;: <br /> �:erveSWVFNk���m <br /> - <br /> ,::::;::::_-:,ter,...._....... _ <br /> EN 23 032 (REV 4/8/91) it Page 11 <br />