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PAYMENT <br /> RECEIVED <br /> OCT 2 2 1992 <br /> SAN IOAQUIN COUNTY <br /> PUBLIC KAI_11-1 SERVICES <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES FNVIRONMFNTALHEALTHDIVISION <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAHE FACILITY CONTACT NAME <br /> F <br /> A <br /> C <br /> I FACILIITTY ADDRESS SITE PHONE A with AREA CODE do W41 3 <br /> L <br /> 1 <br /> T CITS IN <br /> IP CODE I of TANKS <br /> Y �.� at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> LP �� 1 t r <br /> I MAILING ADDRESS APPLICANT PHONE R WITH AREA CODE <br /> C �J s/�' <br /> N CITU Y. f � STATE 21P CODE TYPE ol CLOSURE, INSTALLATION, etc. <br /> A �•l• TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 1100.00 <br /> 1 S <br /> V <br /> F TANK FEE : 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> r R Tanks I 1986 1987 1988 1989 1 1990 1 1991 1 1992 1993 1 1994 1995 1996 <br /> A (multiply Itfee for <br /> C each year applicable) S <br /> I <br /> L STATE SURCHARGE - 256.00 each TANK (Due every 5 years) See California N E S Code, Section 25287 <br /> I <br /> TI Tanks X 256.00 1986 through 1990 1991 through 1996 <br /> T (enter grant and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. I(s) -1 <br /> L CLOSURE FEE = 553.00 per hour (3 hours minlmJm per TANK) f TANK(s)__?_ X 5159.00 5 �p <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. I(a) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 beth TANK 0 TANK(*) X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review E Construction inspections) TARK I.D. I(a) <br /> LiA <br /> N PLAN CHECK FEE - 553.00 per hour (8 hours Minima per Facility) - $424.00 minima S <br /> R REPAIR FEE (workplan review t construction inspections) TANK I.D. I($) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minlimm/TANK) 17ANK(s) X 5159.00 = t: <br /> A <br /> R PIPING REPAIR FEE - $53.00 per hour (3 hour minimm per facility • $159.00) i <br /> N TRANSFER FEE • 520.00 UNAUTHORIZED RELEASE EVALUATION • 553.00/hr S <br /> 1 <br /> 5 <br /> C CONSULTATION FEE - 553.00/hr SAMPLING INSPECTION FEE - 553.00/hr S "� <br /> E USE ONLY TOTAL DUE <br /> OFFI <br /> .� <br /> F'' VEE CTVWfr .. .. a..aiifEft�VESF <br /> I <br /> — —TG'dC9n'1!'v'n.Ti]iluvR --i.'eTA'I:-fi <br /> EH 23 032 (Revised 4/8/91) Page 11 <br />