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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> i FACL{I�STE NAM (CrrF'� FACT IT CONTAC HANE <br /> c FAC//+ITY ADDRESS SITE PHONE with AREA CODE/{Zll <br /> & c d14 /V <br /> CIT SJATE ZIP ; <br /> of TANKS / <br /> A ( LF- 9 eC SITE <br /> P APPLICANT/ LING NAME APP CANT CONTA NA <br /> C S W bl16 I�DYI(S a_ S <br /> AM (LING ADDRE 5 ,�r APPLICANT PHONE If WITH AREA CDpF�� <br /> N iv-iC/A Q( U �tC4 <br /> T CI Y S ATE ZLp CODS TYPE of APPLICATION <br /> U (CLosure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> !6 /Ob $ ZED <br /> T FACILITY PENALTY FEES ASSESSED (If AppLicable) XXXX XXXX S <br /> 1 <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = / 1986 1987 1988 1989 1 1990 1991 1992 1993 1994 1 1995 1 1996 <br /> F (multiply # by fee for c'/� <br /> A each year applicable) 5� � �� U $ D <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX /J $ <br /> L <br /> 4— <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks / x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> ALO $ J LO <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234 00 = S <br /> P INSTALLATION PLAN CHECK (PLan Review & Construction Inspections) Iv. #(s) <br /> L <br /> A / <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) _ �24.00 minimum {� $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #( ) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/T. # TANK X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FAC'LITY) = Y minimum S <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimm/FACILIT ) _ .00 minimum S <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE E ALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr $ <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> ..................................................................................._...__..........._..._._..............................._....__...................................:::_::-:::::::::::::::::::::::::::::::::.—___:__:::::::::::::::::::::::::::::::::::::::::::-.—:::::::::::::::::::::::-::,:-:::::::::::::::::::�:::::::::::::::::: <br /> ............�:::::::�::::::::::::::::::::::::::::::::::::::::::_-::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::�:::::::::::::::::::::::::::::::::::::::::::..._..........................................................................................................._............................................................................. <br /> SWEEPS # CO LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> �j2 <br /> ........................ ....._:........:. ................ _ .......... ....... ....... ................................. <br /> EH 23 032 (REVISED 11-1-92) • Page 11 <br />