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SAN JOAQUIN Co PUBLIC HEALTH SERVICES - ENVIRONMENTAL Ho DIVSION <br /> UNDtKGROUND STORAGE TANK PROGRAI4 - FEE WORKSHEET * <br /> S FACILITY SITE NAME0? � � � FAC L17Y CO CT HA�� <br /> li I I i1/1wU 1, <br /> T <br /> E FACILITY AIRESS SITE PHONE » wit py CODE «!� <br /> CiTY I STji(E Z E a of TANKS 4 - <br /> AI C��Y'�!L If at SITE <br /> P <br /> P1 APPLICANT/81 TING NAME ! 6 r ` APPLI T TAC' A� <br /> I Lm NV_ <br /> -x)ro C� MAI I G ADDRE�S, �� + APPLICANT PH NE 41 WITH A A CODE <br /> A fVl diF` <br /> N <br /> rqt in) <br /> T CIT ST IP 7 E of APPLICATION b <br /> a (Closure, Installation, etc.) <br /> TOTAL <br /> j 1986 1987 1988 i 1989 1990 <br /> AI ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> XXXX XXXX II xxxx <br /> TI FACILITY PENALTY FEES ASSESSED (If Appt+canle) I xxxx I xxxx 1 XXXX I S <br /> [ I <br /> V1 TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E� <br /> Tanks - 1986 1987 i 1988 1989 1990 i 1991 1992 i 1993 1 1994 1995 1996 <br /> Fl (muiriply by reefar <br /> Al each year appiicao(e) xxxx XXXx i xxxx I k I 15 <br /> [ TANK K PENALTY FEES ASSESSED xxxx XXXX I xxxx � I � I � g <br /> L <br /> 11 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & 3 Code, Section 25287 <br /> T1 <br /> YiTanks x 556.00 198$ through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> I <br /> 6'1 FCi PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. +(s) <br /> 01 CLOSURE_FEE = 578.00/hour (3 hours minimum/TANK) TANK(s) x 5234,00 <br /> S' <br /> UI TEMPORARY CLOSURE (Plan Review & Inspections) TANK 1.D, r(s) <br /> R <br /> E� TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum S <br /> PI INSTALLATION PLAN CHECK (P(an Review & Construction Ins?ec:ions)+ TANK I.D. �(S) <br /> Ll <br /> A � 3 / <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) - s624.00 minimum S <br /> R� REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. :(s) <br /> E <br /> P� TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) TANK(s) x 8234.00 = S <br /> A' <br /> I, TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) - 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5Z34.00 minimum S <br /> Al TRANSFER FEE = S20.00 t UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I I $ <br /> C CONSULTATION FEE = 578.00/hr 3 SAMPLING INSPECTION FEE = s78.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> _. ..........._.,_..�_�.._.W -�-- -:G--.......__........ <br /> _....__.a._..._�— ...-..__........_..._ ..._.. ..._.._......_.._....--- --_ -n-.....__.-.- Y,....................... ..._........ - ..._.......,....... <br /> _..............._w......_.....--............__......_.-_........—,-�a-rY........ .._..-.._........._._.._..__....._._. _..�..._._.........__....._ <br /> SWEEPS COMPUTER r I LOC CODE DIST CODE I AMOUNT RECEIVED CHECK T/CASH I RECEIVED 3Y DATE RECEIVED _ <br /> - <br /> _.LS _ _ <br /> EH 23 032 (REVISED 4.29-94) <br />