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SAN JOAQUIN CO PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE A DIVSION <br /> UNDrRGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FAC ITYT E.N E FACILITIY C AC NAME <br /> 1 LC <br /> E FRC AD ESS 1 t SIT H E # th AREA CODE <br /> 1 flGl g <br /> $ 1 TE ZIP CODE # of TANKS <br /> CITY 0_CPCr► at SITE <br /> A u <br /> P APP C T/Sj ING N E APPLI T AMY NAME <br /> L <br /> C MAILING ADDRE S APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N TE ZIP CaDf TYPE of APPLICATION- <br /> T CITY (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January t, 7991) = $100.00 X%%x xXx1f $ <br /> A <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx E <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 7988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply A- y-fee for $ <br /> A each year applicable) xXXX XXXX <br /> I TANK PENALTY FEES ASSESSED I XXXX XXXX $ <br /> 1 STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(a) <br /> L <br /> O CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = E <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimun/FACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimun/FACILITY) _ $624.00 minimum S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 = E <br /> 1 TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 UNAUTXORI2E0 RELEASE EVALUATION = $78.00/hr $ <br /> 1 <br /> ClCONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr $ <br /> TOTAL DUE E <br /> ----..........................................................................._.............._..........................._.........:....::: <br /> ::...........'SilE1=P. ....#......r_C6RPUT.E.R...#...f....0oC.:..LwE....i......B.I..E.1....ME....�.._AMGUFIT�-R�E�LE:TGE6...._:L�HE�t��'-#'J�CA�$TI.......}...._:...RE�LE�I�VEB....8.1,..._:......r--.....CATE�-�R�E�e�ETVEo..............,,, <br /> E <br /> ..........-::....r......................................... ....... .............................................._..._......................_ _..__.............................. i. ....................__....................._...................................... <br /> .............................................._._..:..............................................................................................................................._....................._......................................._._........... _::...............__.............. <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />