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r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME /� FACILITY yCONTACT NAME <br /> C SITE PHONE # with AREA C, ,� <br /> [ FACILITY ADDRESS <br /> Lw <br /> I S ZIP Eln # of TANKS <br /> T CITY at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L APPLICANT PHONE # WITH AREA CODE <br /> I MAILING ADDRESS7 <br /> C f1 <br /> A STATE 71P CODE I TYPE of APPLICATION u� <br /> N CITY CLOSURE., INSTALLATION, etc. <br /> T <br /> TOTAL <br /> A 1985 1987 1988 1989 1990 <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5140,00 5 <br /> 1 <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) S170/TANK (after January 1, 1991) <br /> F # Tanks = 1486 1987 1988 1989 1990 1991 1992 1993 1994 1945 1995 <br /> A (multiply 'f ee for $ <br /> C each year applicable) <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> i <br /> T� # Tanks x 556.00 1985 through 1490 1991 through 1995 <br /> Y (enter amount and year) 5 <br /> PERMANENT CLOSURE (Removal or Authorized CLosure-in-PLace) TANK I.D. #(s) (�5 nr 1 U <br /> CTANK(s)__L_ <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # Q X 5159-D0 = S Jul C <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. *(s) <br /> R # TANK(s) X $150.00 = S <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D- #(s) <br /> L <br /> A = $424.00 minimum S <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) <br /> R REPAIR FEE (workpLan review & construction inspections) TAMC I.D. *(s) <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimnVTANK) # TANK(s) X $159,00 = 5 <br /> A <br /> 1 S <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = 5159.DD) <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S53.00/hr $ <br /> 1 <br /> S 5 <br /> C CONSULTATION FEE = 553.00/hr SAMPLING INSPECTION FEE = 553.00/hr <br /> TOTAL 'DUE <br /> OFF10.-.._U.. ._...k1...,.._....__.._.... ..:...................................... ...: _.. . <br /> ......................:.:.::::::::::::::..:::.::.. ::..:::_::::: _:: :;:.....:::::::::: _....... ._.. ._.... <br /> :::.....:....:...._..._:..........._..:.......-:::::::::_.......................... :.:...._ ..... <br /> r: SuAS # OMPU1. . ..#...._._.LOC OOD �1$Y�CODI�i AMiYJN1rkCVi) CHECK !/�ASFI R�C1VEb § DAY R V 0 w <br /> f �-��- <br /> — ._- <br /> €H 23 032 (REV 4/8/91) ft Page 11 <br />