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SAN JOAQUIN COUNTY�IC HEALTH SERVICES - ENVIRONMENTAL HEALTH •ION <br /> UNDERG STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> SFACILITY SITE NAME <br /> T c— V�k <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & STATE ZIP CCDE # of TANKS <br /> CITY at SITE <br /> P APPLICANT CON E <br /> P APPLICANT/BILLING NAME [f U 2 U <br /> L lis <br /> I APPLICANT PHONE # WITH AREA CPOE <br /> C MAILING ADDRESS _�� <br /> ��I`�`LJ O <br /> A �l <br /> N ST TE ZIP CODE TYPE of APPLICATION <br /> T CITY p (Closure, InstaLLati on, etc.) # 2 <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 $ <br /> A <br /> C xxxX xxxx S <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I5170/TANK (After January 1, 1991) <br /> V TANK FEE = 850.00/TANK (Prior to January 1,1991) <br /> E # Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> = <br /> F (multiply # by fee for S <br /> A each year applicable) <br /> C S <br /> I TANK PENALTY FEES ASSESSED )XXX %XXX <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 2528 <br /> T1991 through 1996 <br /> Y # Tanksx 556.00 1986 through 1990 <br /> (Enter amount and year) 5 <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-PLace) TANK I.D. #(s) <br /> L # TANK(s)_ % 5234.00 = 5 <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimua/TANK) <br /> STANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) <br /> R5 <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) = 5234.00 mini mum <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A $624.00 mini mum 5 <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) <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) % $234.00 = <br /> AS <br /> 1 'TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minim m <br /> R = $234.00 mini mm $ <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACI CITY) <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br /> S <br /> I <br /> S = 578.00/hr 5 <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY _ _ _ __ <br /> _ .............................. ....................................................................................................................................................................... <br /> . ..................................... _ <br /> S E S OM"M7 L <br /> 23 1460 Q �( 3 ? 6 5 .. 3 2.`'� / <br /> 2 6 7- s� » <br /> ......... .............................. .................................... ........................................... <br /> EH 23 032 (REVISED 3-1-93) Pace 11 <br />