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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UMDERGRcumD STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SI FACILITY SITE NAME ..J. �j 6FACILITY CONTACT NAME �^ <br /> E FACILITY ADDRESS SIT PHONE x with AREA CODE <br /> a yL) b/(/ i� /7 CSO q `� It- ,?- 13 6 <br /> Ct <br /> A <br /> CITY �� 1 VC ` / /1STATE _I..JA� at SITE of KS <br /> P C��I�L� -/7 L(� <br /> P APPLICANT/BILL G NAME APPLICANT CONTACT NAME <br /> L � GC- <br /> I <br /> C NAILING ADDRESS APPLICANT PHONE S WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION BRc K <br /> (Closure, Installation, <br /> q() AL <br /> 1986 1987 1988 1989 1990 ��oo <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) • 5100.00 <br /> A xxxx )cx)Ot /00 160 OLS 3'560 <br /> c <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX =CX 00 11,06 116o S 66 <br /> I <br /> V TANK FEE • 550.00/TANK (Prior to January 1,1991) S170/TANK (After January 1, 1991) � (o <br /> E <br /> Y Tanks • -21 1986 1987 1988 1989 1990 1991 11992 1993 1994 11995 1996 <br /> F (multiply N by fee for / _ n f` yy �� /6 <br /> A each year applicable) XXXX XXXX "50 I J �i6 .51015101 ,JID J/O I = "T CC- <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX 15�I t �'� 1� J1 Q J S <br /> L <br /> [ STATE SURCHARGE = 156.00 each TANK (Due every 5 years) See California H 4 S Code, Section 25287 <br /> T <br /> T X Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> I (v e- ' I ) (0 � _ 3 <br /> C PERMANENT CLOSURE (Removal or Authorized Ctasure-in-Place) TANK t.D. a(s) <br /> L <br /> l I <br /> 0I CLOSURE FEE - S78.00/hour (3 hours minimum/TANK) X TANK(s)_ X S234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 4 Inspections) I TANK I.D. x(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - S78.00/hour (3 hours minimuVFACILITY) 5234.00 minimus S <br /> PIINSTALLATION PLAN CHECK (Plan Review is Construction Inspections) TANK I.D. F(s) <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILfTY) = 5624.00 minimus S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. 9(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimMVTANK) X TANK(s) _ X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE 578.00/hour (3 hours minimm/FACILITY) 5234.00 minimus S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.GO/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> SWEEPS ! COMPUTER 7 LOC CODE DIST CODE AMOUNT RECEIVED CHECK J/CASH RECEIVED 8Y DATE RECEIVED 3 <br /> EH 23 032 (REVISED 10-29-93) .... __ Page 11 <br />