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/ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH D[VSION <br /> UNDEJMJM STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS // SITE PHONI C�n'�}?i�(�"1✓� <br /> -��d` <br /> & v) �l �( I <br /> CITY / STATE ZIP CCOE I /� <br /> A GLDn �I G! G! "7�� <br /> P APPLICANT/BILLING NAME APPLICAN'I lye, <br /> C MAILING ADDRESS '5 q APPLICAN <br /> A i /7 UIQ <br /> N U <br /> T CITT STATEZIP CODE TClYPE of APPLIG it W <br /> l//Ll -s ( osure, Install atron, etc.) <br /> TOTAL <br /> 1 ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1986 1987 198Q 19 17 <br /> AS <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) Xxxx I XXXX S <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to Jarwa ry 1,1991) 5170/TANK (After January t, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 11990 1991 1992 1993 1994 11995 1996 <br /> F (mu(tiply tt by fee for <br /> A each year applicable) <br /> I TANK PENALTY FEES ASSESSED I XX)(X XXXX <br /> L <br /> ISTA T'c SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y Tanks x 556.00 1986 through 7990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. tt(s) <br /> L <br /> 0CLOSURE FEE = 578.00/hour (3 hours minimuA/TANK) I tt TANK(s)_ X 5234.00 = S <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 minimm/TANK) # TANK(s) X SZ34-00 = 3 <br /> PINSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) 5624.00 minimum --Ts- <br /> Al <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I 0 TANK(s) _� X 5234.00 = i j <br /> A 00 <br /> 1 TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours mini mm/FACI LITY) = 5234.00 mini mum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> S <br /> C CONSULTATION FEE = 578.00/hr I I SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S 7Y, <br /> FOR OFFICE USE ONLY <br /> SWEEPS At COMPUTER tt I LOC CODE DIST CODE I AMOUNT RECEIVED CHECK 9/CASH RECEIVED BY I DATE RECEIVED <br /> s: <br /> _--__s <br /> EH 23 032 (REVISED 11-1-92) • Page 11 • <br />