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S JAN OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM -FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I ,u 7 EGO P <br /> T SITE PRONE # with AREA CODE <br /> E FACILITY ADDRESS 1 D T —f ZD9 <br /> 3 STATE ZIP CODE # of TANKS <br /> CITY at SITE <br /> A SY oil/ CA <br /> P APPL CANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> AMAILING ADDED �" o� APPLICANT PHONE # WITH AREA CODE <br /> N �-[ Y1 STATE ZIPS TYPE of APPLICATION_ <br /> T CITY (Closure, Installation, at <br /> GO TOTAL <br /> c TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> T # Tanks = 1986 7987 1 1988 1989F)=X <br /> 7991 1992 1993 1994 1995 1996 <br /> I (multiply if�v fee for S <br /> V each year appls icable) XXXX )000( XX%X %XXX <br /> E S <br /> TANK PENALTY FEES ASSESSED XX=U( XXX% XXX=( <br /> S <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T1991 through 1996 <br /> E # Tanks x 556.00 7986 through 1990 <br /> (Enter amount and year) �� S I I y <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 <br /> SI TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> I <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) $234.00 minimum S <br /> L INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> A S <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) 5624.00 minimm <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(a) <br /> — <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = 2234.00 minimum S <br /> N TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> 5 <br /> C CONSULTATION FEE = E78.00/hr SAMPLING INSPECT(ON FEE = 578.00/hr S <br /> TOTAL DUE <br /> _F.:OR_D.f_EICE-ME_(NILY.:::- —=:�_ <br /> � "�SLEEas�1"TitiFialii'ER iF-�C6c t�iSE-�-GTS'I'�'C�'dE-r-Ai�cuWi'�kECE`t'O'Etl tHECK-3F/CaSHs kEC'€IOE�B `DATE�i'Ei:E7tiE15-" <br /> '.a <br /> a <br /> ._ -5-- ----_ —' _....._.,.-.-,tea <br /> EH 23 046 (Revised 7/10/96) Page 11 <br />