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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET S FACIL( SITE NAME FACILITY CONTACT NAME T Z �� E FACT ITY ADORE Sn SITE PHONE # with AREA CODE & J A CITY l STATE ZIP CODE # of TANKS P //lam at SITE P APPLICANT/BILLING NAME APPLICANT CONTACT NAME L I C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE A N T CITY E ZIR CODE PLICATION ajzr&5�0 615-35 (Closure Installation, etc.) TOTAL ANNUAL FACILITY FEE (Prior Co January 1, 1991) = $100.00 1986 1987 1988 1 1989 1990 A $ C T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX $ 1 V TANK FEE = 850.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) E # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1 1994 1 1995 1996 F (multiply # by fee for A each year applicable) g C I TANK PENALTY FEES ASSESSED XXXX XXXX $ L I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 T Y # Tanks x $56.00 1986 through 1990 1991 through 1996 (Enter amount and year) S C PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) TANK I.D. #(s) —3 L 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s)�_ X $234.00 = S J U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) L A N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum $ R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) E P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S A I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ R PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum 5 M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr 5 I S C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = ,578.00/hr S TOTAL DUE $ FOR OFFICE USE ONLY :................................__.........................._..................................................................... .....:...............................::::::::::::_.:::::::::::::::::::..:.....;;....................................................._....................................._................_..................................... :::: :::::::::::::-:�:::::::::::::::_::::�:::::: : :::::::::_::...:::::::::::�::::::::::::::�!rrrs:.=.;_:::::::::::::::::::::::::::::::::::::........_..........................::.:::::.:::::::::::::::::::::::::::::::::::::i:::::::::::::::::::::::::::::::::::::-.......................................................................... :::::........-._............_:.......................................................:::.........._.........................................................................._... ........................ .:...:....:�:::::::::::::::::::a::: _ :::.::..::::::..::-.....r.......... ................:::......:::::::�.......�......... ..................:::;::::;;;;;;:::;:;:;:;:;:::;;_;:[u::tc�c�a:��a< :_:::e:+_:rei:rsrc��a.. ........................._........__............ ...... ..._...........::::::::::::::::::::-::::_......::::_:_::__.._...... ..............._...._._....... .. :::u;.u;:;:e:�: c::tctc......;::;a1-1.1: C LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED in ...... ......................................................................................................................:.:::::::::.._............... ......._.......... _.........::::::.::::::::::::....................................::::::: _._..._. :::::::::::::._:_.::_::::::.............._:........,..,... _. _...._ ..._....._�.:..:..:.............._9..._._..... ............_.....__ ::::.:::::: _:::::�::::::::::_: EH 23 032 (REVISED 11-1-92) 0 Page 11 0