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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE N FACILITY CONTACT NAM <br /> T �^ ^/ <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 9 F'316 -6 rJ <br /> CITY SIA E ZIP CODE # of TANKS <br /> A 43 at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A S AAA <br /> N <br /> T CITY �p ST E ZIP CODELIGATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 2100.00 <br /> A S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX f <br /> t <br /> V TANK FEE - f50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks 1986 1987 1988 19891990 1991 1992 1993 1994 1995 1996 <br /> F (multiply X—by fee for <br /> A each year applicable) 2 <br /> C <br /> 1 TANK PENALTY FEES ASSESSED XXXX XXXX S <br /> L <br /> I STATE SURCHARGE - 256.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y # Tanks x 256.00 1966 through 1990 1991 through 1996 <br /> (Enter amount and <br /> 2 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure•in• ce) TANK I.D. #(s) <br /> 0RE FEE = 278minimm/TANK) # TANK(s) X 2234.00 = 2 O <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - 278.00/hour (3 hours minimum/TANK) # TANK(s) X 2234.00 = 2 <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK 1.0. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 278.00/hour (8 hours minimum/FACILITY) = 2624.00 mini mm f <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.O. #(s) <br /> E <br /> P TANK LINING REPAIR FEE - 278.00/hour (3 hours minimum/TANK) # TANK(s) _ X 5234.00 = 2 <br /> A <br /> I TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) = 2234.00 minimum 2 <br /> R <br /> PIPING REPAIR FEE = 278.00/hour (3 hours minium/FACILITY) = 9234.00 minimum f <br /> X1TRANSFERFEE = 220.00 UNAUTHORIZED RELEASE EVALUATION - 278.00/hr S <br /> S <br /> C CONSULTATION FEE = 278.00/hr SAMPLING INSPECTION FEE - 278.00/hr <br /> TOTAL DUE 2 .d <br /> FOR OFFICE USE ONLY <br /> SwE:PS % COMPUTER # LOC CODE DIST CODE AMW RECEI ED CHECK #/CASH RECEIVED BY GATE RECE I`/EO _ <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br /> v <br />