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r <br /> SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A Hilda Burkhardt Same <br /> I FACILITY ADDRESS SITE PHONE f with AREA CODE <br /> L - <br /> T CITY STATE 21P CODE eoTANKS <br /> tSITE <br /> 0 <br /> Y <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P Same as above Same as above <br /> L APPLICANT PHONE R WITH AREA CODE <br /> I MAILING ADDRESS <br /> C <br /> A STATE ZIP CODE TYPE of APPLICATION TP 5�-^"FQ-Q� <br /> N City CLOSURE, INSTALLATION, etc. }e <br /> T <br /> 70TAL <br /> A 1986 1987 1988 1989 1990 <br /> C <br /> 1 ANNUAL FACILITY FEE (Prior to Jenuary i, 1991) • $100.00 $ <br /> V5170/TANK (after January 1, 1991) <br /> E TANK.FEE 150.00/TANK (prior to January 1,1991) <br /> F N Tanks • 1986 1987 1988 1989 1990 1991 1992 1993 1996 1995 1996 <br /> A (multiplyT y�yfee for S <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE • $56.00 each TANK (Due every 5 years) See California N L S Code, Seetlon 2528 <br /> I1991 through 1996 <br /> 1 1 Tanks x $56.00 1986 through 1990 <br /> Y (entererrant and year) f <br /> PERMANENT CLOSURE (Removal or Authorized Closure-In-Place) TANK I.D. f(s) <br /> C f3 <br /> L CLOSURE FEE • 553.00 per hour (3 hours minimum per TANK) 1 TANK(s) % $159.00 <br /> 0 <br /> 5 <br /> U TEMPORARY CLOSURE (A ane-flaw• permit, for review/Inspections) TNR I.D. (s) <br /> E TEMPORARY CLOSURE FEE • $150.00 each YANK <br /> R 7ANK(a) _ X $150.00 $ <br /> PI PUN CHECK (Install. Plan Review 6 Cotntructl on Inspections) - <br /> L <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimus per Feellity) • 1626.00 minimum S <br /> R REPAIR FEE (workplen review $ construction irepectl") TANK I.D. f(a) <br /> P TANK REPAIR FEE • $53.00 per hour (3 hours minlmX !159.00 <br /> m/TANK) f TANK(s) <br /> 1 <br /> A <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility • !159.00) <br /> H TRANSFER FEE • !20.00 UNAUTHORIZED RELEASE EVALUATION - 153.00/hr <br /> f <br /> CI N <br /> CONSULTATION FEE 153.00/hr SAMPLING INSPECTION TEE • 153.00/hr 1733 <br /> TOTAL DUE S159-00 <br /> `4 7 <br /> ® v'1 <br /> EN 23 032 (Revised 4/8/91) Page 11 <br /> r <br />