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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVS10M <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WDRXSHEET <br /> S FACIL{jYIS� AME <br /> I �� <br /> FACILITY CONTACT NAME <br /> T <br /> E FACTY ADDRESS �� SITE PHONE # with AREA CODE <br /> IL <br /> a J <br /> A CITY T ZIP CODE # of TANKS <br /> �,5 Q <br /> P at SITE <br /> P APPL ANT/ LLING NAME APPLICANT CON CT NAME _ <br /> I 1 ) � <br /> c MAILING RISS t) APPLICANT PHONE ! WITH AREA CODE <br /> A <br /> M <br /> T CIT AZIP CODE TY PLICATION <br /> closure 'Installation etc.) <br /> TOTAL <br /> 1986 1987 1 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) 5100.00 <br /> A xxxx xxxx — 5 KOO — <br /> c <br /> T <br /> I FACILITY PENALTY FEES ASSESSED (If Applicable) XXXx XXXx S 30o "J <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = / 19861987 1988 1 1989 1 1990 MIE3 1994 19951996 <br /> F (multiply # by fee forA each year applicable) xxxXXXXX oC _I TANK PENALTY FEES ASSESSED XXXX xxXx 5 <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H a S Cade, Section 25287 <br /> T <br /> Y # Tanks x $56.001988 through 1990 1991 through 1996 <br /> (Enter amount and year) _ <br /> ( `; 5 �— <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE - 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review a Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimua/FACILITY) $234.00 minimAa 5 <br /> P INSTALLATION PLAN CHECK (Plan Review a Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review a Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE - 578.00/hour (3 hours minimum/TANK) # TANK(s) _ X 5234.00 = 5 <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 578.00/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 = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE 5 <br /> FOR OFFICE USE ONLY <br /> mg <br /> SWEEPS Al COMPUTER # LOC CODE DIST CODE I AMOUNT RECEIVED CHECK #/CASH RECEIVED 8Y DATE RECEIVED <br /> EH 23 032 (REVISED 10-28-93) Page 11 y <br />