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SAN O QUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIROtf,VMXTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM -FEE WORKSHEET <br /> s p I FACILIT CONTACT NA - e/6'7 ....�C)E)6 <br /> S FACILITY SITE NAM rn (� <br /> T I' S[TE PHONE # with AREA CODE <br /> T <br /> E FAC(IIT ADDRESSS <br /> & TE ZIP CODE I Y of TANKS <br /> CITY w52� as SI7E <br /> A I APPLI AHj CONTACT NAME <br /> P S or <br /> WCG <br /> P APPLICANT/BILLING NAME O C f"G <br /> L I APPLI:ART PHONE X WITH AREA CODE <br /> I <br /> ' Zo 73 ^ V3 <br /> C (LING ADOR`SS C�p /7.7 <br /> A I T APPLICATION <br /> R STATE( �P COOE los r , Installation, etc.) <br /> T CITY <br /> S L roiaL <br /> AI TANK FEE = 550.00/TANK (Prior co January 1,1997) <br /> 5170/TANK (Af:er January 1, 1991) <br /> T X Tanks = 1986 11987 11988 11989 11990 1991 1992 i 1993 i 7994 i 1995 i 1996 5 <br /> I (multiply fee far <br /> �y XXXX I XXXX %XXX XX%X XXXX <br /> Y each year applicable) � 5 <br /> I <br /> I XXXX XXX% I XXX% I XXXX XXXX <br /> ETANK PENALTY FEES ASSESSED <br /> I STATE SURCHARGE = $56.00 each TANK (Owe every 5 years) See California X & S Cale, Section 2528 <br /> 5 <br /> T 1986 through 1990 1997 ch rough 1996 <br /> E i Tanks x 556.00 5 <br /> (Enter amount and year) <br /> Ci PERMANENT CLOSURE (Removal or Authorized CLosure-in-?lace) i TANK I.D. ;:i % 5234.00 = 5 O Z <br /> Oj CLOSURE F.__ /TANK) I TE = 578.00/hour <3 hours minimusANK(s) <br /> VTANK I.D. R(s) <br /> UI TEMPORARY CLOSURE (Plan Review 3 Inspections) 5 <br /> R 5234.00 minimus <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimus/FACILITY) <br /> i <br /> P INSTALLATION PLAN CHEC�h (8 <br /> view & Construction inspections)] TANK I.D. <br /> L S ,?TtiY7l`� <br /> A = 5624.00 minimum <br /> NI PLAN CHECK FEE = 578.0hours minimus/FACILITY) <br /> TANK I.D. 4(s) <br /> RI REPAIR FEE (Workplan Review & Construction inspec:ians) I 5 <br /> E' TANK(5) X 5234.00 = <br /> PTANK LINING REPAIR F'cE = 578.00/hour (3 hours mini 5 <br /> A = 5234.00 minimum <br /> i TANK RETROFIT REPAIR FEE = 5$.00/hour (3 hours min./FACILITY) 5 <br /> R = 5234,00 minimum <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minims/FACILITY) <br /> M TRANSFER FEE = 520.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br /> 5 <br /> I I I 5 <br /> 5 <br /> C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = S78.00/hr <br /> _ TOTAL DUE 7b Z <br /> __ESR,4;F_F:_I;CE:U;SE_p[l,T,..--_=_--_ T=—__.. _ ^-----_ -- <br /> SYE:?S a< COMPUTE :-LOC COO rJIST CClJE—�aM(X1N1�c�C�I`JEJ CHECK— GSH <br /> REC'_`7-V ED 3Y JATc NEC'c 1VE3 '' <br /> EH 23 046 (Revised 7/10/96) Page I1 <br />