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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM -FEE WORKSHEET <br /> 5 F ILI TY SIT NA F CILITY CO TACT NAME <br /> T /1 e I' <br /> E FACILITYe.DRE ,_,., NONE # with AREA CODE <br /> a , <br /> V C[jY,l 1l $T/�,TE ZI,P�7i��o at of SITE <br /> NKS <br /> P <br /> AP((fLI NT/BILLING NAME Lf� cj A PLICAN CQNyq.CT NAME <br /> I EMC b LL" &U47' <br /> A RAILING ADDRESS PLI NT PHONE # WITH AREA CODE <br /> M C" sz -4(2 <br /> T CI]Y, ,�T/1TE Z P CODE TYPE of APPLICATION ,, <br /> DG�?5�u �1b �jS?iS� (Closure, Installation, etc.) P2 <br /> TOTAL <br /> C TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> T # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> I (multiply #S—fee for <br /> E each year app tcahle) XXX% XXXX XXXX XXXX XXXX S <br /> TANK PENALTY FEES ASSESSED I XXXX XXXX XXXX XXXX XXXX S <br /> S <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> E # Tanks x 856.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> 0 CLOSURE FEE = 578.00/hour (3 hours mini mum/TANK) # TANK(s)_2.1 X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimus S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.O. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = 5624.00 mini mm S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE - 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 8234.00 mini mm S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = f234.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> C CONSULTATION FEE = $78.00/hr <br /> S SAMPLING INSPECTION FEE = $78.00/hr S <br /> TOTAL DUE tl D <br /> ._.OILOf.E.LCE,:USE:::Q11LT::.—„ - -- <br /> � suEEas"#-"'�tbMauTER # Lbs �oDE (—bIST CDDri`AMbUNr REINA rE—RECEtiVEDy <br /> 'w <br /> _ -e.que_ugm:nsv�ns� <br /> .:....nmmgs..r—. <br /> EN 23 046 (Revised 7/10/96) Page 11 <br />