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i 0 <br /> SAN JOAQUIN COUNTY PUBLIC I)EALTH SERVICES <br /> ENVIRONb1ENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAIN -FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I (l pl. S <br /> E FACILIADDRESS , S TE PHONE # with AREA CODE <br /> EAR -3 <br /> 6 STATE ZIP CODE # of TANKS <br /> A <br /> CITY � gZ( D at SITE 3 <br /> Cd <br /> P APPLICANT CONTACT NAME <br /> P APP CANT/81LL ING NAME '�" �lA <br /> I `L„ AkPPLICANT PHONE It WITH AREA CODE <br /> MAILING <br /> (1DORE,S ,� �Typfe ZL(�'l(ppTATE ZIP CODETIONC[7Y llation, etc.) <br /> lab <br /> TOTAL <br /> a TANK FEE = 550.00/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 /> = <br /> I eachc ear ' yifee for ; <br /> V each year applicable) X%XX XXXX X%%% %%%% %%%% <br /> E E <br /> TANK PENALTY FEES ASSESSED X%%K XXXX XXXX %XX% XX%% <br /> s <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> E # Tanks z $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> 0 CLOSURE FEE = 878.00/hour (3 hours minimum/TANK) # TANK(,)_ X $234.00 = E <br /> S TANK I.O. #(s) <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) <br /> RE <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review 8 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 S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ % $234.00 = S <br /> AE <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 mini mm <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum E <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> i <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE <br /> .--., <br /> .........__.............. . ..................................=:c_.............__._ <br /> ......._........................... ...---'--._..............__............._._..__._._..:-_=.—a :::::_:::_—_,::::c:::_.—:_.::_-::-:,:.—::::-:E�:f---'EEE=�s_t3tFE-='EfE=EtFp:?5::—?---�_'_tsc"_ia <br /> ::S::::::::::::::::�::::::: �::M �E��F:::s=:s��EEE:::s:a=_:::EEE::::m-..__—:,::��::-:::::-::.�:_--:::::::::-:-::-::--:::...r-.......... <br /> "sWEEpS"# coMPUYEk Y Lal: tDBE o!'sY CDDE AMDuxf RECEIVED ��iiEtR"�Ii'A�d —RE'CE'IVE6 81' riAYE RECEIVE6 ; <br /> :::::::::::::::.::::::::::-::-:::-r: :: .-......._.....__............................ ..........�_-::-:- _......__._......_.__ <br /> _ <br /> --:in <br /> : . ..... .............:.... <br /> Ell 23 046 (Revised 9/11/96) Page 11 <br />