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SAN JOAQUIN COUNTYP' BL IC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UHDERG STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ( <br /> SITE NAME FACILITY CONTACT NME <br /> Barbara Campbell Same <br /> SITE PHONE M with AREA CODE <br /> CILITY ADDRESS N/A <br /> 213 E. Oak St. <br /> STATE ZIP CODE N of TANKS <br /> A CITY Lodi , CA 95240 at SITE 1 <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME Saine <br /> L Barbara Campbell <br /> 1 APPLICANT PHONE M WITH AREA CODE <br /> C MAILING ADDRESS (209)222-8210 <br /> A 1751 W. Santa Ana <br /> N STATE ZIP CODE TYPE of APPLICATION Removal <br /> I CITY (Closure, Installetlon, etc.) <br /> Fresno, CA 93705 <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 $ <br /> A <br /> Cxxxx xxxx s <br /> I FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) <br /> 5170/TANK (After January 1, 1991) <br /> E <br /> m Tanks 1_ 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply IT by fee for X X s112.00 <br /> A each year applicable) X X X X X X <br /> C S <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx <br /> L <br /> I STATE SURCHARGE _ %56.00 each TANK (Due every 5 years) See California N d S Code, Section 2528 <br /> 1 1986 through 1990 1991 through 1996 <br /> y B Tanks x $56.00 <br /> (Enter amount and year) f <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. M(a) <br /> LM YANK(s) 1 % %234.00 = $234.00 <br /> u <br /> 0 CLOSURE FEE _ $78.00/h our (3 hours minimn/TANK) <br /> STANK I.D. p(s) <br /> U TEMPORARY CLOSURE (Plan Review 6 Inspections) <br /> R $234.00 mini" f <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimus/FACILITY) <br /> P INSTALLATION PLAN CHECK (Plan Review 6 Construction Inspections) TANK I.D. M(s) <br /> L <br /> A = %624.00 minimus f <br /> N PLAN CHECK FEE _ %78.00/hour (8 hours min irtuNFACILI TY) <br /> R REPAIR FEE (Workplan Review d Construction Inspections) TANK I.D. N(a) _ <br /> E 11 $234.00 = $ <br /> P TANK LINING REPAIR FEE _ %78.00/hour (3 hours minimum/TANK) N TANK(5) <br /> A f <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) - %234.00 minimum <br /> R = $234.00 mini mum <br /> % <br /> PIPING REPAIR FEE _ %78.00/hour (3 hours mi nimxm7FACILy 1Y) <br /> N TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br /> s <br /> I <br /> 5 $78.00/hr $ <br /> C CONSULTATION FEE _ %78.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE •346•U� <br /> ssrs Rx. . .................................................................�................................................................................................................. <br /> .... <br /> FOR OffICE.USE ONLY ........................... .. ...... .......I f I, j UAIE kIVhIP a <br /> .«..,..,.,.m. ` 1 <br /> asqt� "1°�'ET�E°�` <br /> ■ <br /> SliE E1i5 � OTXP�t�� LUT: aPA��E? � ■ <br /> a <br /> c,zxrrm sat wm w'vmr. w"°�iw wwwirw�maaxt sa wzxa�www wo wilt wxAarAv�at�w■natam arswmwfr■x+�■xwtwrtAwrt■Awawrew■wwwawwswrww <br /> Ell 23 032 (REVISED 3-1-931 Pane 11 <br />