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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGRCL= STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY ITE NAME FACILITY CONTACT NAM p <br /> T ev �� S <br /> E FACILITY ADDRESSSITE PHONE h AREA CODE <br /> & c� a0 wit - ala 3 <br /> CITY TE ZIPS=EX of TANKS <br /> A J D at SITE J <br /> P <br /> P APPLICA T/SELLING NAME APPLICANT CONTACT NAME' <br /> L / <br /> I <br /> C MAILING ADORES APPLICANT PHONE 0 WITH AREA CODE <br /> A W/( <br /> M <br /> T CITYTE ZIP CODE TYPE of APPLICATION <br /> �' j (Closure, Installation, ate.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> C <br /> Xxxx Xx)D( )C?C I nD t 6o 5 °D <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX %XX% X t 00 /O f Uv O <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks ) 1986 1987 1 1988 1 1989 1 1990 1991 1 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX )C= x X( 5ol Sol 170 / 70 s <br /> C <br /> ITANK PENALTY FEES ASSESSED X)(XX X%%X Ix x1 O D I �� / O S D OD <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California 4 & S Code, Section 25287 <br /> T <br /> Y # Tanks L x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) _ -1 <br /> & '� <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0I CLOSURE FEE - 578.00/hour (3 hours minimum/TANK) # TANK(S)_ X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimun/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK 1.0. #(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) 5624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) # TANK(s) _ X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.001hour (3 hours minimm/FACILITY) = $234.00 minimm 5 <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 378.00/hr I S <br /> t <br /> S <br /> C CONSULTATION FEE 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr $ <br /> TOTAL DUE s 73 <br /> FOR OFFICE USE ONLY <br /> SWEEPS S COMPUTERS LOC CODE DIST CODE I AMOUNT RECEIVED CHECK ;O/CASH RECEIVED 3Y DATE RECEIVED <br /> S <br /> EH Z3 032 (REVISED 10-28-93) 1W --- Page 11 c;2""3-?At ��� <br />