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SAN JOAQUIN CENT PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEAL-li DIVSION FAY (p 50 <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET `%(p 3 <br /> S FACILITY SITE NAME o \ ` l FACILITY CONTACT MAKE <br /> I \ ar/' �plNn V✓�'1 Si`��CO/� � 1'� 'S-J ') WtJ Td <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> RU �c <br /> 8 <br /> •A C(TYS CODE\ �\ ^ STATE ZIP CE # of TANKS <br /> 'C�� 'cam C� at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME f <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N N �SoO G✓ t�r . <br /> I CITY STATE 219 CODE TVLAL APPLICATION <br /> S��� ^ , y'r0( losure Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A OC MID S -Z 9CS <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx )000 XXXX lCtD (Ou <br /> I <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for ,t. <br /> A each year applicable) SD G(7 60 170 170 C)CD S (� <br /> C )O=I TANK PENALTY FEES ASSESSED )OX)XX X)0(% _o Sp 7 O 7� 't 70 — - S <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) q <br /> �-z S (o SitZ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours miniaun/TANK) # TANK(s) X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimm/FACILITY) = $234.00 minimum S <br /> .P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minima VFACILITY) = $624.00 minimum f <br /> R REPAIR FEE (Workp(an Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) __— X 5234.00 = f <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum f <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimm/FACILITY) = $234.00 minimm S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> S <br /> L CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ <br /> TOTAL DUE S 2 <br /> FOR OFFICE USE ONLY ✓�� <br /> g.......................... ........................ ........ 1...... .._3 s.........0.............. ..... r�3_��.:.'........ ....__ . <br /> EH 23 032 (REVISED 3-1-941 Pace 11 <br />