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SAN JOAQUIN CONTY PUBLIC HEALTH SERVICS - ENVIRONMENTAL HEALTH DIVSIOI <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORLSHEET <br /> Sl FACILI Y SITE NAME I FACILITY CONTACT NAME <br /> T I A� + 1 <br /> ELi FACILI T ADDRESS �'+ I SITE PH x rich AREA CCOE <br /> CITY I STATE ZIP CODE x of TANKS <br /> A at SITE <br /> P <br /> P APPIIGNT/B ILL LNG NAME APPA WT CONTACT NAME <br /> l <br /> C MAILING AOORESS I APPLICANT PHQME x WITH AREA CODE <br /> A 3 <br /> N <br /> T CITY STA ' ZIP CODE TY f APPLICATION -Fnp Qq,�mo, /,`' `��`;','/ C <br /> C (Clos , Installation, etc. T L��KK.� . <br /> TOTAL <br /> 1986 I 1987 11 I 1989 I 1990 ) <br /> ANNUAL FACILITY FEE (prior to January 1, 1991) = 5100.00 <br /> A )0= ! xxxx Ii /00-� /DO 5 <br /> FACILITY PENALTY FEES ASSESSED (If ADplicabl@) I XXXX XXXX (� <br /> I , <br /> VTANK FEE = 550.00/TANK (Prior ;a January 1,1991) 5170/TANK (After January 1, 1991) <br /> E -L. I 1 I I 1 I <br /> S tanks = 1986 1987 1988 1989 � 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply = oY ree Por _ <br /> A each year applicable) I XXX)( 14001 150 I5 I ! //-7 <br /> 01 Mlt-70I I S 60 <br /> LTANK PENALTY FEES ASSESSED I XX%X AXXX I Ah I J DIS I 111 I S <br /> I <br /> 11 STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H S S Cade, Section 25247 <br /> TIx Tanks, x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> CI PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK 1.0. $(s) <br /> L' <br /> OI CLOSURE FEE - S78.00/hour (3 hours :minimum/TANK) ( x TANK(S)_ X 5234.00 = s <br /> S <br /> Ui "EMPORARY CLOSURE (Plan Review 3 (nspectiens) TANK I.D. *(a) <br /> El TEMPORARY CLOSURE FEE - S78.00/hour (3 hourm ,IiniaLM/FACILITY) I 5234.00 :minimm S <br /> PI INSTALLATION PLAN CHECK (Plan Review 3 'wwtructi0n Insoectiern)I TANK I.O. x(s) <br /> L' <br /> A) <br /> NJ PLAN CHECK PEE = S78.30/hour (8 hours minimm/FACCLITY) = S624.00 minimus S <br /> Rl REPAIR FEE (Vorkplan Review i Canstructlon IMO*ctians) I TANK 1.0. x(S) <br /> Pj TANK LINING REPAIR =£ = S78.00/hour (3 hours minimum/TANK) I 3 TANK(s) X 5234.00 = S <br /> A <br /> Ii TANK RETROFIT REPAIR FE. = 578.00/hour 13 hours :min./FACILITY) = 5234.00 minimum 5 <br /> R <br /> I PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = M4.00 minimus S <br /> Al "RANSFER 7— • 520.00 I UNAUTHORIZED RELEASE EVALUATION TION - S78.00/hr S <br /> S' <br /> Cl CCUSULTATICH FEE = 578.00/hr l I SAMPLING INSPECTION FEE = 578.00/hr S ` <br /> TOTAL DUE 5 <br /> FOR OFFICE USE 71LY <br /> iwEEPS x i COMPUTER = LCC E GIST CODE AMO)NT RELIVED CHECK. %/USX AEC:-:, 3Y i TATE tEC'ci`IED a <br /> H 3 032 (REVISED '0-ZS-93) <br />