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SAN -JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION
<br /> UNDERG'' 11) STORAGE TANK PROGRAM - FEE WORK511EET
<br /> S FAFILITY SITE NAME FACILITY CONTACT16ME
<br /> T
<br /> E FACILITY ADDRESS SITE PHONE # With AREA CODE
<br /> g 2.2
<br /> CI 4 ;STAIEZIP CODE
<br /> � # of TANKS
<br /> A O at SITE
<br /> P �
<br /> P APPLICANT/8ILLING NAME y 1 APPLICANT CONTACT NAME
<br /> I C�1�t'l Y'v VA l VL - U✓PO-`r-,D/\J CA c-\
<br /> C NAILING ADDRESS APPLICANT PHONE # WITH AREA CODE
<br /> T CITY STATE ZIP CODE iYP PLICATION
<br /> C\,j Closure nstaltacion, etc.) C�WS e�—_ _
<br /> TOTAL
<br /> 191361987 T988 1989 1990
<br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00
<br /> A XXXX xxxx xxxx xxxx xxxx $ xxxxxxxx
<br /> C
<br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx xxxx xxxx xxxx S xXxxxxxx
<br /> I
<br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991)
<br /> E
<br /> 0 Tanks = 1988 1 1989 1990 1 1991 1992 1993 1994 1995 1996 1997 1998
<br /> F (multiply # by fee for
<br /> A each year applicable) XXXX xxxx xxxx xxxx xxxx I 5
<br /> C
<br /> I TANK PENALTY FEES ASSESSED xxxx xxxx xxxx xxxx xxxx 5
<br /> L
<br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 5
<br /> T
<br /> Y Tanks x $8.00 1988 through 1993 ($56) 1993 through 1997 (S56) 1998
<br /> SURCHARGE FOR 1998 xxxxXxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx S
<br /> C PERMANENT CLOSURE (Removal or Authorized C(osure-in-Place) TANK I-D. #(s)
<br /> L
<br /> 0 CLOSURE FEE = 578,00/hear (3 hours minimwn/TANK) # TANK(;) X 5234,00 = S
<br /> S
<br /> U TEMPCRARY CLOSURE (P(an Review K Inspections) TANK I.D. #(s)
<br /> R
<br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.+00 minimum S
<br /> P INSTALLATION PLAN CHECK (Pian Review $ Construction Inspections) TANK I.D. #(s)
<br /> L
<br /> A
<br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = $624.00 minirtua S
<br /> R REPAIR FEE (Workplan Review 3 Construction inspections) TANK I.O. #(s)
<br /> E
<br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimua/TANK) # TANK(s) X $234.00 = S
<br /> A
<br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min-/FACILITY) _ $234.00 minimum 5
<br /> R
<br /> PIPING REPAIR FEE _ $78-00/hour (3 hours minimum/FACILITY) $234.00 minimum S
<br /> N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578-00/hr S
<br /> I
<br /> S
<br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr S
<br /> TOTAL DUE 5
<br /> FOR OFFICE USE ONLY
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<br /> EH 23 032 (REVISED 1-12-98)
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