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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMEMTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FAC�CITY SITE NAME c FACILITY CONTACT NAME <br /> E FACILITY ADDRESS - SITE PHONE # with AREA CODE <br /> Sf <br /> CITY `-f' STATE ZIP CODE # of TANKS <br /> A at SITE <br /> P <br /> P APPLICA T/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I ' <br /> C MAILIN 0DRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> it CITY (`, / G ��^ / STATE ZIP CODE TYmc of APatI <br /> /CIns losure [ns tallati on, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ =100.00 <br /> C1 Oo'� o6'1 p.o0 eco / no =500 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %XXX I XXXX (cd 5 23 G10 <br /> V1 TANK FEE _ =50.00/TANK (Prior to January 1,1991) 6170/TANK (After January 1, 1991) <br /> E,' <br /> F (nulN ply fee for 1986 11987 1988 1989 1990 1991 1992 11993 1994 1995 1996 <br /> A each year applicable) -:50- 1450-1,50 '56 56 /")v = Gq <br /> LTANK PENALTY FEES ASSESSED %XXX I XXX% I sv 5 —I -)�J 7 o <br /> I STATE SURCHARGE = =56.00 each TANK (Due every 5 years) See California H!!& S Code, Section 25287 <br /> T <br /> Y 3 Tanks x =56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> s1sc� <br /> `I PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> ILL <br /> oI CLOSURE FEE = =78.00/hour (3 hours minimum/TANK) # TANK(s) X =234.00 = _ <br /> S <br /> UI TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = =78.00/hour (3 hours minimum/TANK) # TANK(s)_ X =234.00 = S <br /> PI INSTALLATION PLAN CHECK (Plan Review & Construction Inspecti ans)� TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimm/FACILITY) _ =624.00 minimum 5 <br /> RI REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> PI TANK LINING REPAIR FEE - S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = =78.00/hour (3 hours min./FACILITY) = 5234.00 mini mm S <br /> R <br /> PIPING REPAIR FEE = 578.00APur (3 hours minimum/FACILITY) _ =234.00 minimum S <br /> MI TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr $ <br /> 1 <br /> S. <br /> CI CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S / Cr Y <br /> FOR OFFICE USE ONLY <br /> SwBEPS- PUTER # CODE I DIST CODE AMOUNT RECEIVED I CHECK */CASH RECEIVED BY DATE RECEIVED 3 <br /> S <br /> EH 23 032 (REVISED 11-1-92) 4 Page 11 <br /> • <br />