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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> T �CI ITY SITE NAME FACILITY CONTACT NAME <br /> ( Q <br /> E FACILLT ADDRESS SITE PHONE # with AREA CODE <br /> 8 _ L L- <br /> CITY TATE ZIP CODE # of TANKS <br /> A at SITE <br /> P, <br /> P APPLICANT/BIL LNG NAME APPLICANT <br /> L h <br /> CONTACT NAME <br /> I <br /> C MAILING A NRESS _ APPLICANT PHONE # WITH AREA CODE <br /> A 'C'C L1_. 'C. <br /> N - <br /> T CITY TATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Instatlati on, etc.) <br /> TOTAL <br /> Al TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> C' <br /> T # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> I (multiplyi�'oy—fee for <br /> V each year applicable) x%x% xxxx XXX% XXx% Xxxx S <br /> E <br /> TANK PENALTY FEES ASSESSED IXXX% XXXX XXXX XXX% X%XX S <br /> S <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> E # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (RemovaL or Authorized Closure-in-Place) TANK I.O. #(s) <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimae/TANK) # TANK(s)__J__ X 5234.00 = E a <br /> 5 <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours miniexm/FACILITY) 5234.00 minimum S <br /> PI INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) -- <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S �— <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimus <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimae 5 <br /> MTRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr $ -^ <br /> I <br /> 5 <br /> C� CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S -� <br /> off' <br /> TOTAL DUE 2.�C�• <br /> :::FOR_,Of,E,ISE,SISETQML.T_::=...__.. _........ :-::::.----._-.._—.--.-..- -....._...____.--- <br /> -Ea <br /> aH <br /> $UEEfff— UTER—F-i LSCC—CODE EL`ciYEDr-CHECK:i/CA$A REC`"c'tVED $Y —1SATE REtE <br /> _..._. _....._.._.._._-:.......:......._............. .._... ........._._..._............. _:....:...—: ::........::... a <br /> EH 23 046 (Revised 9/11/96) Page 11 <br />