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SAN JOAQUIN COUNTY-'UBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTI' n MION <br /> UNDER MO STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SI FACILITY SITE NAME FACILITY CONTACT NAME <br /> I T , <br /> I <br /> E FACILITY ADDRESS SITE PHONE # ui h AREA CODE <br /> a 2 S - � � — 3S <br /> CITY I STATE ZIP CODE # of TANKS <br /> A to at SITE <br /> P <br /> P APPLICANT/BILLING NAME 'CANT CONTACT, NAM <br /> L \ \J� <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N (. <br /> T CITY ST TE ZIP ODE TY P APPLI CA <br /> v­_ C( — C.' ��}S� ( tosur Installation, etc.) C <br /> TOTAL <br /> 1 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 1986 1987 1988 1989 1990 <br /> A I XX)C( XXXX = <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) I XXXX XXXX I 5 <br /> I <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> F $Tanks # by fee for 11986 11987 11988 11989 11990 1991 1992 11993 1994 1995 1996 <br /> A each year applicable) XXXX XXXX I I I S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX I I _ I I I S <br /> Lr- <br /> 11 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H a S Code, Section 25287 <br /> T <br /> Y # Tanks X S56.D0 1988 through 1990 1991 through 1996 <br /> (Enter amour[ and year) <br /> S <br /> C1 PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.O. #(s) `Jif 7 Z <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) <br /> _� X 5234.00 = s <br /> S <br /> U TEMPORARY CLOSURE (Plan Review a Inspection) TANK I.D. #(s) <br /> x <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours miniaam/FACILITY) I 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review a Construction Inspection) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) _ ;624.00 minimum 5 <br /> E1 REPAIR FEE (Workplan .Review i Construction Inspections) TANK 1.0. #(s) <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> [ TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> x <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 mini mm S <br /> M TRANSFER FEE = s20.00 I UNAUTHORIZED RELEASE EVALUATION - 578.00/hrI s <br /> S• I I I <br /> CI CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE - 578.00/hr s <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> 3 SVEEPS # I COMPUTER S I LCC CCDE DIST CCOE I AMOUNT RECEIVED CHECK S/GSH I RECEIVED 3Y I DATE RECEIVED <br /> EN 23 032 (REVISED 10-28-93) Page 11 <br />