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SAN JOAQUIN COUN1 JBLIC HEALTH SERVICES ENVIRONMENTAL HEALT,— nION D <br /> UNDERMGOUND STORAGE TANK PROGRAM - FEE WORKSHEET nn <br /> S FACILITY SITE NAM FACILITY CONTACT NAME <br /> I <br /> L Sffl G�YIS . <br /> "e FACILITY ADDRESS - SITE PHONE R with AREA CODE <br /> CITY // , - � STATE ZIP CODE R of TANKS <br /> A S (✓ "Zry� ��. OC� at SITE <br /> P <br /> P APPL CANT/BILLING NAME APPLICANT CONTACTE <br /> VN a C a P� f v J i=R i C— i e n ° <br /> C MAILING ADDRESS APPLICANT PHONE / WITH AREA CODE <br /> T CITY J SrAr ZIP CLUE TYPE APPLICATICN <br /> 5���- \`'�7�LJ asure Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) 5100.00 � <br /> C/ i $ l0 0 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXX% ID10— S C <br /> I <br /> V TANK FEE 550.00/TARK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> c <br /> s Tanks • 1986 1987 1988 1989 1990 1991 1992 1943 994 1995 996 <br /> F cm (tiply $by fee for r <br /> A each year eppOceble) �O �J� �O �7U �'� 170 <br /> C y <br /> I TANK PENALTY FEES ASSESSED KXXX XXXX so D D ��U 17(� I !�i S <br /> L <br /> ISTATE SURCHARGE • $56.00 each TANK (Due every 5 years) See California H 4 S Code, Section 25287 <br /> r <br /> Y a Tanks K S56.00 1986 through 1990 1991 through 1996 <br /> (Enter aaornt and year) / <br /> CPERMANENT CLOSURE (Removal or Authorized Closure-in•Place) TANK I.D. R(s) '� <br /> L <br /> 0 CLOSURE FEE • S78.00/hour (3 hours miniaam/TARK) Al TANK(s) X $234.00 - <br /> S i <br /> U TEMPORARY CLOSURE (Plan Review S faspectfons) TANK I.D. $(a) <br /> R <br /> E TEMPORARY CLOSURE FEE • $78.00/hour (3 hours minfaam/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review L Coraitruction Irupectiotu) TANK I.D. 5(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $78.00/hour (8 hours minfmm/FACILITY) • 5624.00 mini aan S <br /> R REPAIR FEE (Vorkplsn Review S Coretruction Irspectiordl) TANK I.D. #(a) <br /> E <br /> P TANK LINING REPAIR FEE . $78.00/hour (3 hours mfniatm/TANK) Al TANK(s) _ X SZ34.00 It <br /> A <br /> I TANK RETROFIT REPAIR FEE a 578.00/hour (3 hours min./FACILITY) a 5234.00 minds S <br /> R <br /> PIPING REPAIR FEE 578.00/hour (3 hours minimum/FACILITY) + S234.00 mini aan 9 <br /> M TRANSFER FEE %20.D0 UNAUTHORIZED RELEASE EVALUATION • S78.00/hr 5 <br /> i <br /> S <br /> C CONSULTATION FEE • S78.00/hr SAMPLING INSPECTION FEE a 578.00/hr S <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY <br /> ss��I��i�lAifir�#f/�Y#aa�s/ar/as ssss�ia�Isf�a ilk##!•fYAOa�s ssrafe�/f/l�#aaelfa#rs% <br /> EH Z3 032 (REVISED 3-1-431 <br />